Mr. W is an 83-year-old man who was brought to the hospital from a long-term care
facility by emergency medical services after reporting severe dyspnea
... [Show More] and shortness of
breath. He has been experiencing coldlike symptoms for the past 2 days. He has a
productive cough with thick yellowish sputum. When Mr. W awoke in the nursing home,
it was found that he was having difficulty breathing even after using his albuterol
metered-dose inhaler (MDI). He appears very anxious and is in respiratory distress. His
history includes chronic obstructive pulmonary disease (COPD) related to smoking 2
packs of cigarettes per day since he was 15 years old; he quit smoking 2 years ago
when he was admitted to the long-term facility. Mr. W has been incontinent of urine and
stool for the past 2 years.
In the emergency department, Mr. W undergoes chest radiography, and admission
laboratory tests are performed, including serum electrolyte levels and a complete blood
count. A sputum sample is sent to the laboratory for culture and sensitivity testing and
Gram staining.
Mr. W's *vital sign values* are as follows:
-Blood pressure: 154/92 mm Hg
-Heart rate: 118 beats/min
-O2 saturation: 88% on 1 L/min oxygen by nasal cannula
-Respiratory rate: 38 breaths/min
-Temperature: 100.9° F (38.3° C) (oral) - ANSWhich *priority* actions will the nurse take when the patient is initially admitted to the
emergency department (ED)? *Select all that apply.*
•Place the patient on a cardiac monitor
•Get a baseline set of vital signs
•Draw admission labs and place a saline lock
•Change the patient's adult pad
•Send the patient for a chest x-ray
•Order the patient a lunch tray - ANS-•Place the patient on a cardiac monitor
•Get a baseline set of vital signs
•Draw admission labs and place a saline lock
•Send the patient for a chest x-ray
•Baseline data that are essential to decisions for the care of this patient take priority at
this time including vital signs, cardiac rhythm, lab values, and chest x-ray findings.
Placement of a saline lock is essential for administration of fluids and emergency drugs.
Changing the patient's incontinence pad is important to protect his skin but is not urgent.
Ordering a lunch tray may be premature because the interventions for this patient's care
are undecided when he is first admitted to the ED.
What is the *priority* nursing concern for this patient?... [Show Less]