A nurse is caring for a patient who has sepsis.

The patient has been prescribed vancomycin 1 g in 250 mL dextrose 5% (D5W) to be administered over 2 hours via IV intermittent bolus.

How many mL/hr should the nurse set the IV pump to deliver?

Choice A rationale

While observing the patient’s respiratory status is important in all patient care, it is not the priority action in this case. The patient’s decreased level of consciousness and inability to swallow increase the risk of aspiration, which can lead to respiratory complications.

Choice B rationale

Elevating the head of the patient’s bed 30° to 45° is the priority action. A patient who has a decreased level of consciousness and an inability to swallow is at risk for aspiration. Lying down also increases this risk. The priority action by the nurse is to keep the head of the bed elevated to promote gastric emptying and reduce the risk of aspiration.

Choice C rationale

Monitoring intake and output every 8 hours is important for assessing the patient’s hydration status and nutritional needs. However, it is not the priority action in this case. The risk of aspiration due to the patient’s decreased level of consciousness and inability to swallow takes precedence.

Choice D rationale

Checking residual volume every 4 to 6 hours is a standard practice when administering continuous enteral feedings through a gastrostomy tube. It helps to ensure that the patient is tolerating the feedings and not at risk for aspiration due to high gastric residuals. However, in this case, the priority is to prevent aspiration by elevating the head of the bed.

Choice A rationale

While gastric acid can cause dyspepsia, measuring gastric residual is not primarily done to remove gastric acid.

Choice B rationale

Measuring gastric residual is primarily done to identify delayed gastric emptying. This is important because delayed gastric emptying can lead to complications such as aspiration pneumonia.

Choice C rationale

Gastric residual does not directly determine the patient’s electrolyte balance.

Choice D rationale

While confirming the placement of the NG tube is important, it is not the primary purpose of measuring gastric residual.