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Handoff report at 11:00 PM: "Mrs. J, 88 years old, was admitted this evening from a skilled nursing facility. The family says the patient was lethargic and confused during their visit. Her admitting vital signs were T 101° F, P 92 and irregular, R 28 and short and shallow, BP 110/70, pulse ox 94%. Her physician was called for admitting orders and was informed of the UA report from the skilled nursing facility. He will come in tomorrow morning to see her. She was given acetaminophen at 8:30 PM and her current temperature is 100.6° F; she is still slightly confused. She has an IV infusing. She is in a private room." Mrs. J's flowcharts contain the following information: [TABLE] [TR] [TD] Nursing Care Kardex VS q4h Diet: DAT LBM: On admission IV: 0.9% NS at 75 mL/hr #24 angiocath RFA Lab: CBC, chem. panel, UA PRN Medication: Acetaminophen 325 mg tabs ii q4h prn temp greater than 101° F [/TD] [TD] Nurse's Notes from Skilled Nursing Facility Documentation of latest nurse's notes: 1600 Turned, incontinent of urine, strong urine odor, incontinent pad applied............A. Cann LVN 1700 Family in to visit. Upset, called physician...............................................A. Cann LVN 1830 Transferred to hospital per order. Recent UA culture reports show + MRSA. Unable to contact physician to inform. Copy of report included with transfer. .....................T. Gage RN [/TD] [/TR] [/TABLE] It is now 11:30 how would Iprioritize my plan of care of the next hour