A client is ordered to receive 1000ml of 0.9% saline over 4 hours. At what rate will the nurse set the IV pump in mL/hr? (Enter a number only).

A) The nurse formulates a goal "The client will be free from infection for the duration of the hospitalization": This action reflects the planning phase of the nursing process. The planning phase involves setting goals and determining the best interventions to achieve the desired outcomes for the client. In this case, the goal is to prevent infection, which is a specific, measurable outcome that can guide further interventions.

B) The nurse assesses the client's white blood cell count: Assessing the client's white blood cell count is an important step in data collection, which is part of the assessment phase of the nursing process. It helps the nurse gather information about the client's current health status but is not a planning activity. The nurse would use the information from the assessment phase to formulate goals and plan interventions.

C) The nurse administers the ordered oral antibiotics: Administering antibiotics is an action related to the implementation phase of the nursing process. The implementation phase involves carrying out the planned interventions. In this case, the administration of antibiotics is a direct action taken to address the risk for infection, but it is not the planning phase.

D) The nurse teaches the client the appropriate hand washing technique: Teaching hand hygiene is an important intervention, but it falls under the implementation phase of the nursing process. It involves educating the client to help prevent infection, which is an action taken based on the goals and plan developed earlier. While important, it’s not the planning phase itself.

A) Shake bottle well, pull ear outward and downward, instill drops: This method is typically used for younger children, such as infants or toddlers, as the ear canal in younger children is more horizontal. However, this is not the appropriate method for a 12-year-old.

B) Shake bottle well, pull ear outward and upward, instill drops: This method is incorrect because the ear should be pulled outward and upward for a child under 3 years old, not for a 12-year-old.

C) Warm bottle in hand, pull ear outward and upward, instill drops: This is the correct method for a 12-year-old client. The ear should be pulled outward and upward to straighten the ear canal, allowing the drops to reach the deeper parts of the ear. Additionally, warming the bottle in your hands prevents discomfort that might arise from cold drops being instilled in the ear.

D) Warm bottle in hand, pull ear outward and downward, instill drops: This method is appropriate for children under 3 years old. For children older than 3 years, the ear should be pulled upward to open the ear canal.