An IV infusion of 125 mL of a GI prokinetic agent is ordered to be given over 1 hour. The nurse will use a microdrip infusion set (60 gtts/mL). How many drops per minute will the drug infuse at the proper rate?

Use a preceding zero if necessary. Do not use trailing zeros.

To calculate the infusion rate in drops per minute:

1. Identify the total volume to be infused: 125 mL
2. Identify the total time for infusion: 1 hour (which is 60 minutes)
3. Identify the drop factor: 60 gtts/mL

Step 1: Calculate the infusion rate in mL per minute.

• Volume (mL) ÷ Time (minutes)
• 125 mL ÷ 60 minutes = 2.0833 mL per minute

Step 2: Calculate the infusion rate in drops per minute.

• Infusion rate (mL per minute) × Drop factor (gtts/mL)
• 2.0833 mL per minute × 60 gtts/mL = 125 gtts per minute

The drug will infuse at 125 drops per minute.

Choice A Reason:

“You should share this thought with your psychiatrist.”

This response suggests that the client should discuss their harmful thoughts with their psychiatrist. While it is important for the client to communicate openly with their mental health provider, this response does not directly address the nurse’s ethical and legal obligation to report threats of harm. The nurse has a duty to ensure the safety of others, and simply redirecting the client to another professional does not fulfill this responsibility. According to the Tarasoff rule, healthcare providers have a duty to warn potential victims if a client poses a credible threat.

Choice B Reason:

“I can make that promise to you based on nurse-client privilege.”

This statement is incorrect because nurse-client privilege does not extend to situations where there is a threat of harm to others. Confidentiality in healthcare is crucial, but it has limits, especially when it comes to preventing harm. Nurses are legally and ethically obligated to report any threats of violence or harm to appropriate authorities to protect potential victims. Making such a promise would be misleading and could result in serious consequences.

Choice C Reason:

“Those kinds of thoughts will make your hospitalization longer.”

This response is inappropriate as it focuses on the potential consequences for the client rather than addressing the immediate concern of a threat to another person’s safety. It may also discourage the client from being honest about their thoughts in the future. The primary responsibility of the nurse in this situation is to ensure the safety of the client and others, which involves reporting the threat to the appropriate authorities.

Choice D Reason:

“I cannot promise that. Confidentiality does not include plans to hurt others.”

This is the correct response. It clearly communicates to the client that while confidentiality is important, it does not cover plans to harm others. The nurse must explain that they are obligated to report any threats of violence to ensure the safety of potential victims. This response aligns with legal and ethical guidelines, which mandate that healthcare providers report credible threats of harm.