A hospice nurse is caring for a client who has a fentanyl patch applied. The client appears restless and agitated. Which of the following actions should the nurse take?

Let's break down the steps:

Total volume to be delivered: We know the volume of the sodium chloride solution is 100 ml.

Concentration of cefazolin: The concentration is given as 1 gram of cefazolin in 100 ml of solution. Therefore, the concentration is 1 g / 100 ml = 0.01 g/ml.

Delivery time: The infusion needs to be delivered over 30 minutes, which is 0.5 hours (since 1 hour = 60 minutes).

Drop factor: The drop factor is 15 gtt/ml, which tells us how many drips it takes to deliver 1 ml of fluid.

Now, we can calculate the rate (flow rate) of the infusion in gtt/min:

Rate = (Total volume) / (Delivery time)

Rate = (100 ml) / (0.5 hours) = 200 ml/hour

Since we know the drop factor, we can convert the rate from ml/hour to gtt/min:

Rate (gtt/min) = Rate (ml/hour) * Drop factor (gtt/ml)

Rate (gtt/min) = 200 ml/hour * 15 gtt/ml = 3000 gtt/hour

Finally, round the rate to the nearest whole number:

Rate (rounded gtt/min) = 3000 gtt/hour ≈ 50 gtt/min

Therefore, the nurse should set the manual IV infusion to deliver approximately 50 gtt/min.

A. “Heart rate”: While it’s important to monitor the heart rate of a client who has received naloxone, it’s not the first assessment that should be made. Opioid toxicity can lead to life-threatening respiratory depression, so the priority is to assess the client’s respiratory status.

B. “Pain level”: Pain level is an important consideration when administering any medication, but it’s not the first assessment to be made following naloxone administration. The priority is to assess the client’s respiratory status, as opioid toxicity can cause life-threatening respiratory depression.

C. “Blood pressure”: Monitoring blood pressure is important in any client receiving medication, but it’s not the first assessment to be made following naloxone administration. The priority is to assess the client’s respiratory status, as opioid toxicity can cause life-threatening respiratory depression.

D. “Breath sounds”: This is the correct answer. The primary risk with opioid toxicity is respiratory depression, which can be life-threatening. Naloxone is administered to reverse this effect. Therefore, the nurse should first assess breath sounds to determine if the client’s respiratory status is improving.