Ati Fundamental Case Study

ATI FUNDAMENTAL CASE STUDY A 70-year-old female has been admitted to the hospital. THE CLIENT has had nausea and vomiting for the past three days. Upon admission the client is slightly confused and weak. Her vital signs are: 99 F (37.2 C), respirations 20 breaths/minute, pulse 102 beats/minute, BP 96/66 mm Hg, and her pain level is an “8”on a scale of 0-10. Breath sounds are clear bilaterally upon auscultation. Pulse oximetry is 95% on room air. Bowel sounds are absent in the right and left lower quadrants and in the left upper quadrant. Abdomen is hard and distended. When questioned as to her last bowel movement, the client responds, “I have not moved my bowels in over one week.” Mucous membranes dry; skin turgor poor. The HEALTH CARE provider (HCP) orders the following: 1. IV of Lactated Ringers (LR). Infuse 1 Liter of LR over 6 hours by infusion pump now. When completed infuse LR at 100 mL/h 2. Insert indwelling urinary catheter to straight drainage 3. Obtain urine analysis (UA) and urine culture and sensitivity (C& S) 4. Insert nasogastric (NG) tube to intermittent suction 5. Diet: NPO 6. Vitals signs every 4 hours 7. Labs: CBC and electrolytes stat 8. Monitor I & O every shift 1. The HCP ordered 1 Liter of LR to infuse over 6 hours. Calculate the flow rate you will program the infusion pump. 167 mL/h (round to the nearest whole number). 2. The client states she has pain to her left forearm four (4) hours after the start of the infusion. Upon inspection and palpation of her forearm, the NURSE notes redness and swelling at the IV site and the forearm is warm to touch. What is the initial action the nurse should take? Stop the infusion 3. What are the recommended nursing interventions when an IV becomes infiltrated? What are the recommended nursing interventions when phlebitis is noted? Intervention for infiltrated: Stop infusion ,discontinue line, elevate extremity, apply heat or ice per facility policy Intervention for phlebitis: Stop infusion ,discontinue IV line, apply warm moist packs 4. A urine culture C& S is ordered. How would the nurse obtain a urine C& S from a indwelling urinary catheter? Drain the catheter’s tubing of urine. Clamp the catheter’s tubing below the port for 20 min. Wipe port with alcohol or other approved cleanser. Use surgical asepsis while withdrawing the required amount (30 mL) from the port with a syringe. Unclamp the catheter. Send specimen to lab immediately in a biohazard container