A client is to receive 250 mL of IV fluid over 90 minutes by gravity.

The drop factor on the IV tubing is 20 gtts/mL. How many gtts/min should be administered?

Choice A rationale

Elevating the head of the bed reduces blood pressure and intracranial pressure. Loosening restrictive clothing addresses triggers of autonomic dysreflexia, while checking the catheter resolves bladder-related stimulus for this medical emergency.

Choice B rationale

Although elevating the head of the bed is correct, applying a cool compress doesn't address the root cause of autonomic dysreflexia. The compress offers temporary relief without resolving the underlying triggers.

Choice C rationale

IV access and oxygen application are secondary interventions. The priority is resolving triggers like bladder distension or tight clothing to prevent further autonomic dysreflexia complications.

Choice D rationale

Placing the patient in a supine position can exacerbate hypertension and intracranial pressure. This positioning fails to address triggers of autonomic dysreflexia and is contraindicated in this condition. .

Choice A rationale

Reviewing the safety data sheet does not directly alleviate the immediate chemical injury or prevent further damage. Immediate irrigation of the eyes is the priority after chemical exposure to minimize damage to the ocular surface.

Choice B rationale

Continuous irrigation removes chemical agents from the eyes and prevents further damage. Ensuring a pain-free state and checking pH confirm the removal of irritants, essential for preventing deeper eye tissue damage.

Choice C rationale

Miotic drops reduce intraocular pressure but do not address acute chemical injury. Pain relief is secondary to irrigating and neutralizing pH, which directly prevents ongoing tissue damage and irritation.

Choice D rationale

Assessing visual acuity and vital signs is important but secondary to preventing further chemical penetration. Immediate irrigation prevents damage progression and is prioritized over assessments during the acute phase of exposure.