Answer Happy

Scenario: The patient is transferred to amedical unit 2 hours after arriving at the emergency departmentwith an admitting diagnosis of pyelonephritis. She has a history ofasthma and type 2 diabetes mellitus. The admitting nurse isassessing the patient and reviewing orders and diagnostic studiesto develop a plan of care. The patient is awake, alert, andpleasant but is not oriented to place and time. She reorientseasily with frequent reminding. She is complaining of pain but isnot able to use the pain intensity scale. Ibuprofen is prescribedfor pain every 6 hours as needed. Vital signs are temperature101.4◦ F, pulse 100 bpm, respirations 22 breaths perminute, blood pressure 138/74 mm Hg. The patient is receivingintravenous normal saline at 100 mL/hour. A urine specimen was sentto the lab for culture and sensitivity. She is tolerating her clearliquid diet well. The nurse began an infusion of an extendedspectrum cephalosporin as soon as the urine specimen was obtainedand sent to the lab. The patient is voiding frequently and althoughinstructed to do so, does not ask for assistance to ambulate to thebathroom.
1. NGN Item Type: Extended Response
Based on the patient’s current treatment plan, the patient’spriority needs will be to prevent which of thefollowing? Select all that apply.
_____ G. Pressure wound
Rationale for your choices:
Cognitive Skill: Prioritize Hypotheses
2. NGN Item Type: Extended Drag and Drop
Indicate which nursing response listed in the far-leftcolumn is appropriate for each client question. Note that not allresponses will be used.
Nurse’s Responses
Patient Questions
Appropriate Nurse’s Responsefor each Patient Question
“How much longer will I have this pain in the side of myback?”
“Why do I have to pass my water so frequently?”
“When will this needle be removed from my arm?”
“Will I be able to walk around in my room today?”
“Can I take this medicine as a pill instead of through theneedle in my arm?”
Rationale for your choices:
Cognitive Skill: Generate Solutions