A nurse is assessing a client following the administration of an initial dose of captopril. Which of the following findings indicates an anaphylactic response?

Step 1: Total volume = 1000 mL (which is 1 liter)

Step 2: Total time = 2 hours. But since the infusion pump rate is typically set in mL per minute, we need to convert this to minutes. There are 60 minutes in an hour, so 2 hours is 2 × 60 = 120 minutes.

Step 3: Now we can calculate the rate. The rate is the total volume divided by the total time. So, the rate = 1000 mL ÷ 120 minutes.

Calculating the above gives us the rate at which the nurse will set the infusion pump. Let's calculate it:

Step 4: Rate = 1000 mL ÷ 120 minutes = 8.33 mL/minute.

So, the nurse will set the infusion pump at a rate of approximately 8.33 mL per minute. If rounding is required, this can be rounded to 8.3 mL per minute.

Choice A reason: A client with type 1 diabetes mellitus who has taken a high dose of insulin is at significant risk for hypoglycemia. In type 1 diabetes, the body does not produce insulin, so insulin therapy is essential for controlling blood glucose levels. However, if the dose of insulin is too high relative to the patient's dietary intake or physical activity level, it can lead to a rapid decrease in blood glucose levels, resulting in hypoglycemia. Hypoglycemia is defined as a blood glucose level less than 70 mg/dL (3.9 mmol/L) and can cause symptoms such as confusion, sweating, weakness, and in severe cases, seizures or loss of consciousness.

Choice B reason: A client with type 2 diabetes who has not taken any medication may have elevated blood glucose levels but is not typically at immediate risk for hypoglycemia unless they are taking medications that lower blood glucose. Type 2 diabetes is characterized by insulin resistance, and while medication can help manage it, skipping medication does not usually result in hypoglycemia unless other factors are at play.

Choice C reason: An older adult client taking an antibiotic for an infection is not generally at risk for hypoglycemia unless the antibiotic interacts with other medications that the client is taking for diabetes management. Antibiotics themselves do not typically cause hypoglycemia.

Choice D reason: A client who has metabolic syndrome and is taking a statin drug to lower cholesterol levels is not at direct risk for hypoglycemia from the statin medication. Metabolic syndrome is a cluster of conditions that increase the risk for heart disease, stroke, and type 2 diabetes. While statins are used to lower cholesterol levels, they do not have a direct impact on blood glucose levels that would lead to hypoglycemia.