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

Increased collagen is not a factor that would lead to a pressure injury in a client with impaired mobility. Collagen is a protein that helps in the formation of skin and other connective tissues.

Choice B rationale

Decreased serum calcium is not directly related to the development of pressure injuries. While calcium is important for bone health and muscle function, it does not play a direct role in skin integrity.

Choice C rationale

Increased muscle mass is not a risk factor for pressure injuries. In fact, good muscle mass can help distribute pressure more evenly and potentially reduce the risk of pressure injuries.

Choice D rationale

Decreased circulation is a major risk factor for the development of pressure injuries. When blood flow to an area of the body is reduced, the tissues in that area can become deprived of oxygen and nutrients, leading to cell death and the formation of pressure injuries.

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.