1145 Patient HJ is a 87 year

1145 Patient HJ is a 87 year old man who has a diagnosis of altered mental status. He has a Glasgow Coma Scale of 12. Vital signs are as follows. P 86, RR 15, MAP 82, O2 sat 89% on room air, temp 37, pain 1/10. Wife states that “he’s starting to lose it”. HJ has a poor nutritional status and is frequently confused. 1207 The CNA was feeding HJ some oatmeal when he became agitated and started screaming. The call light is going off and you assess your patient. Vital signs are as follows: P 102, RR 20, MAP 110, O2 sat 82%, temp 37, pain 1/10. Patient is red in the face and is gasping. Lung sounds have coarse crackles in all lobes. EKG shows sinus tachycardia. The nurse has received the following orders. Select which 2 orders are of the highest priority? a. Prepare for V/Q scan b. Give beta blocker for hypertension c. Give Ativan for anxiety d. Obtain blood cultures and send to lab for sensitivity e. Continuous telemetry f. Obtain chest X-ray g. Titrate O2 to saturation of 90% SCIENCE HEALTH SCIENCE NURSING NURS 4130

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