A nurse is preparing to infuse a 250-mL unit of packed red blood cells (RBCs) over 2 hours.

The drop factor of the manual intravenous (IV) tubing is 15 drops/mL. How many drops per minute should the nurse adjust the flow rate to deliver?

Choice A rationale:

Administering oxygen at 2 L/min via nasal cannula is a common intervention for patients experiencing respiratory distress or hypoxia. However, in this scenario, the client’s oxygen saturation is 96%, which is within the normal range. Administering oxygen unnecessarily can lead to complications such as oxygen toxicity, especially in patients with chronic conditions like COPD. The client’s rapid and shallow breathing is likely a response to pain and anxiety rather than a primary respiratory issue. Therefore, addressing the underlying cause of his symptoms, such as pain management and anxiety reduction, would be more appropriate.

Furthermore, the client’s medical history includes hypertension and type 2 diabetes mellitus. These conditions can complicate the administration of oxygen therapy. For instance, patients with hypertension may experience increased blood pressure with supplemental oxygen, and those with diabetes may have altered respiratory responses. It is crucial to consider these factors before initiating oxygen therapy.

In summary, while oxygen therapy is a vital intervention for hypoxia, it is not indicated in this case due to the client’s normal oxygen saturation levels and the need to address pain and anxiety first.

Choice B rationale:

Preparing the client for immediate surgery is a drastic measure that should only be considered if there is a clear indication of a life- threatening injury or condition that requires surgical intervention. In this case, the client has a visible abrasion on his right elbow and complains of pain in his right hip. While these symptoms are concerning, they do not necessarily indicate an immediate need for surgery.

The client’s vital signs, although elevated, do not suggest a life-threatening condition. His temperature is slightly elevated, which could be due to pain or anxiety. His pulse and respirations are elevated, likely due to pain and anxiety as well. His blood pressure is elevated, which is consistent with his history of hypertension. These vital signs do not indicate a need for immediate surgical intervention.

Additionally, the client’s medical history of hypertension, type 2 diabetes mellitus, and osteoarthritis must be considered. These conditions can complicate surgical procedures and increase the risk of complications. Therefore, a thorough assessment and diagnostic imaging, such as X-rays or CT scans, should be performed to determine the extent of the injury before considering surgery.

In summary, immediate surgery is not warranted based on the current assessment. Further evaluation and diagnostic imaging are necessary to determine the appropriate course of action.

Choice C rationale:

Applying a cold pack to the client’s right hip is an appropriate intervention for several reasons. First, the client is experiencing pain in his right hip, which could indicate a soft tissue injury, contusion, or even a fracture. Applying a cold pack can help reduce pain and swelling in the affected area, providing immediate relief.

Cold therapy, also known as cryotherapy, works by constricting blood vessels, which reduces blood flow to the injured area. This helps to decrease inflammation and swelling, which can alleviate pain. Additionally, cold therapy can numb the affected area, providing further pain relief.

The client’s medical history of osteoarthritis is also relevant. Osteoarthritis can cause joint pain and stiffness, and cold therapy is often recommended to manage these symptoms. By applying a cold pack to the right hip, the nurse can help manage the client’s pain and prevent further complications.

In summary, applying a cold pack to the client’s right hip is a safe and effective intervention to manage pain and swelling. It addresses the client’s immediate discomfort and is consistent with best practices for managing soft tissue injuries and osteoarthritis.

Choice D rationale:

Assisting the client to a standing position and assessing his ability to bear weight on the right leg is not appropriate at this stage. The client has reported pain in his right hip, which could indicate a serious injury such as a fracture. Attempting to stand or bear weight on the affected leg could exacerbate the injury and cause further harm.

Before assessing the client’s ability to bear weight, it is essential to conduct a thorough assessment and obtain diagnostic imaging to determine the extent of the injury. This may include X-rays or CT scans to rule out fractures or other serious conditions. Once the extent of the injury is known, a more appropriate plan of care can be developed.

Additionally, the client’s medical history of osteoarthritis should be considered. Osteoarthritis can cause joint pain and stiffness, making it difficult for the client to bear weight on the affected leg. Forcing the client to stand or walk without proper assessment and support could lead to further injury and complications.

In summary, assisting the client to a standing position and assessing his ability to bear weight on the right leg is not appropriate at this stage. A thorough assessment and diagnostic imaging are necessary to determine the extent of the injury and develop a safe and effective plan of care.

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.