A client receives a prescription for 1 L of lactated Ringer's IV to be infused over 12 hours. The IV  administration set delivers 15 gtt/mL. How many gtt/min should the nurse regulate the infusion? 
(Enter numerical value only. If rounding is required, round to the nearest whole number.) 

Rationale

A. This finding suggests that the skin has already broken down, indicating a more advanced stage of pressure injury rather than an early indication. The presence of broken skin typically indicates at least a Stage 2 pressure injury according to the staging system.

B. This description suggests the presence of a deep tissue injury (DTI), which is a late sign of pressure injury.

C. This is indicative of a stage I pressure injury, where the skin is still intact but shows signs of redness that does not blanch with pressure. This stage precedes the actual breakdown of skin seen in more advanced pressure injuries.

D. This finding describes a superficial wound with clear margins, suggesting a Stage 2 pressure injury. It is more advanced than the early signs typically sought for early intervention.

A. Allowing the client to find a comfortable position can help reduce anxiety and promote relaxation, which can be beneficial during an asthma exacerbation.
B. While the patient is currently receiving treatment with albuterol and oxygen, discussing aggressive respiratory treatment options may not be necessary at this moment unless the patient's condition deteriorates and requires escalation of care.
C. Deep tracheal suctioning is not indicated based on the current assessment findings unless there is a specific clinical indication such as excessive secretions or respiratory distress.
D. Identifying and discussing potential triggers is important for asthma management. This helps the client understand what factors might exacerbate their asthma and how to avoid them in the future.
E. Since the patient's oxygen saturation is still below target (91% on room air), weaning the supplemental oxygen is not appropriate at this time. The oxygen therapy should be continued as per the titration orders to maintain saturation above 94%.
F. Obtaining a sputum culture is not typically indicated in acute asthma exacerbations unless there is suspicion of a secondary infection or if the patient develops persistent fever and productive cough.
G. Continuously monitoring oxygen saturation is crucial to ensure it remains above 94%. This helps gauge the effectiveness of treatment and ensures the patient's respiratory status is stable.
H. Positive pressure ventilation is a more advanced intervention and is not indicated based on the current assessment findings. It would only be considered if the patient's condition worsens despite maximal medical therapy.