The nurse is about to administer 1 liter (1000 mL) of 0.9% NS over 2 hours intravenously to a patient in shock.

What rate should the nurse set on the infusion pump?

Based on the provided exhibits, the client is most likely experiencingBacterial Meningitis. This is indicated by symptoms such as severe headache, fever, sensitivity to light, nuchal rigidity, and the presence of Neisseria meningitidis in the cerebrospinal fluid with elevated white blood cell count and lactic acid levels.

The two actions the nurse should take to address this condition are:

1. Anticipate administering antibiotic therapy- This is crucial as the client’s culture and sensitivity test indicates the presence of Neisseria meningitidis, which requires antibiotic treatment.
2. Place the client on droplet precautions- Since Neisseria meningitidis can be spread through respiratory droplets, it is important to implement droplet precautions to prevent the spread of infection.

The two parameters the nurse should monitor to assess the client’s progress are:

1. Level of consciousness- Monitoring for changes in the client’s level of consciousness can indicate the effectiveness of the treatment and the progression of the disease.
2. Increased intracranial pressure- Signs of increased intracranial pressure can include changes in vital signs, level of consciousness, and the presence of headache or vomiting. Monitoring these signs is important in the management of bacterial meningitis.

Choice A rationale
A 33-year-old with burns to the back and shoulders. While this patient’s injuries are serious, they are not immediately life-threatening. The back and shoulders are not vital areas, and while pain management and wound care will be necessary, this patient’s situation is not as urgent as others.
Choice B rationale
A 32-year-old with burns on the hands and face. This patient should be attended to first. Burns on the hands and face are more serious due to the high risk of infection and the potential for complications such as impaired breathing if the airway swells or becomes blocked due to the burns. Immediate treatment can help to prevent these complications.
Choice C rationale
A 42-year-old with burns on both legs. While these burns are serious, they are not immediately life-threatening. The patient will need pain management and wound care, and may have mobility issues, but their vital organs are not directly impacted by the burns.
Choice D rationale
A 25-year-old with a burn on the left arm. This patient, while in need of treatment, is not the highest priority. A burn on the arm, while painful and requiring treatment, is not as potentially serious or life-threatening as burns to the face, hands, or major portions of the body.