During shift report a colleague states that there is 350 mLs remaining in the client's IV and it has to infuse for 2 more hours. The nurse confirms this matches the order. If the drip factor is 12 gtts/ml, what is the current IV rate? DOCUMENT ANSWER IN THIS FORMAT: RATE gtts/min (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

A. Complete the remainder of the assessment: While ongoing assessment is important, the rhythm strip shows atrial flutter, a potentially unstable arrhythmia, and the client is experiencing symptoms (nausea after breakfast) which could suggest compromised cardiac output. Completing the remainder assessment delays the necessary intervention.

B. Obtain an order for adenosine IV: Adenosine is typically used for stable supraventricular tachycardia (SVT), not for atrial flutter, as it may not terminate the rhythm. It may slow conduction enough to better visualize flutter waves, but initiating it without a provider's order or further evaluation is inappropriate.

C. Notify the physician of the symptoms: The client’s rhythm strip shows atrial flutter with a rapid ventricular response and the patient is experiencing nausea, which could indicate decreased perfusion or early decompensation. Immediately notifying the provider is the safest and most appropriate action for further evaluation and treatment planning.

D. Administer the prescribed ACE inhibitor: ACE inhibitors are used for blood pressure control or heart failure management, not for acute rhythm disturbances. Administering it would not address the current rhythm or symptoms and could worsen hypotension if cardiac output is compromised.

A. Assist the client from the stretcher to a wheelchair: Immediately after electroconvulsive therapy (ECT), the client is still recovering from anesthesia and may experience confusion, drowsiness, or muscle weakness. Transferring the client prematurely poses a fall risk and is not appropriate as the first action.

B. Orient the client and offer reassurance: While reorientation and reassurance are important aspects of post-ECT care, safety and physiological stability must be assessed first. This action should follow an initial assessment of vital signs and level of consciousness.

C. Encourage the client to drink some fluids: Offering fluids too soon after ECT is inappropriate because the client may have impaired swallowing reflexes from anesthesia or sedation. Ensuring the airway is clear and the client is fully alert must precede oral intake.

D. Assess vital signs and orient client to the PACU environment: The priority after any procedure involving anesthesia is to assess vital signs to ensure hemodynamic stability and monitor for complications. Once stable, the nurse can begin to orient the client, which is often needed after ECT due to temporary disorientation or memory lapses.