The healthcare provider prescribes 100 mL of 0.9% normal saline to be infused within 15 minutes. The nurse should program the infusion pump to deliver how many mL/hr? (Enter numerical value only.)

Choice A reason: Encouraging deep breathing and coughing exercises is generally important postoperatively to prevent respiratory complications. However, it is not specific to eye surgery and does not address the immediate care needs following the removal of glass from the eye.

Choice B reason: Obtaining vital signs every 2 hours during hospitalization is a standard postoperative procedure to monitor for complications. While important, it is not an intervention specific to eye surgery and does not directly address the protection and care of the operated eye.

Choice C reason: Providing an eye shield to be worn while sleeping is a crucial intervention immediately following eye surgery. The eye shield protects the operated eye from accidental injury, rubbing, or pressure during sleep. This helps to prevent complications and promotes healing by keeping the eye safe from potential harm while the client is unaware.

Choice D reason: Teaching a family member to administer eye drops is important for ongoing postoperative care. However, it is not the immediate priority following the surgery. The first step is to ensure the protection of the eye, which can be achieved by providing an eye shield. Teaching about eye drop administration can be done later as part of the discharge instructions.

Rationale for Correct Choices

Option 1: Impaired gas exchange is the priority problem because the client's oxygen saturation is critically low at 88%, and the assessment reveals expiratory wheezes, rapid respirations (28/min), and severe shortness of breath. These indicate difficulty in maintaining adequate oxygenation.

Option 2: "I used my rescue inhaler three times, but I couldn’t catch my breath." This statement directly indicates that the asthma attack is unresponsive to the usual medication, highlighting the severity of the impaired gas exchange.

Rationale for Incorrect Choices

Option 1:

A. Anxiety: While anxiety may be present, it is a secondary issue caused by the asthma attack and is not the root cause of the client’s symptoms.

C. Ineffective airway clearance: Although wheezing suggests partial obstruction, the critical issue is the impaired oxygenation and low oxygen saturation rather than mucus or secretions obstructing the airway.

D. Activity intolerance: The client’s difficulty breathing is not primarily due to exertion but rather to the asthma attack itself.

Option 2:

A. "I was jogging when it started.": This identifies the trigger for the attack but does not explain the severity or lack of response to medication.

C. "My symptoms are worse when outdoors and when exercising.": This is helpful for identifying long-term triggers but does not prioritize the immediate issue of unrelieved shortness of breath.

D. "I noticed my inhaler was expired and was worried the medication was not working.": While this points to a lapse in medication management, it does not address the acute respiratory distress.