A nurse is preparing to administer 0.9% sodium chloride 1,000 mL. IV to infuse over 8 hr. The nurse should set the IV pump to deliver how many mL/hr? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero)

A. Response to stimuli: The client was responding to internal stimuli, such as hearing helicopters and believing they are being pursued. Responding to hallucinations is a hallmark sign of psychosis.

B. Affect: Affect refers to the observable expression of emotion. While the client’s agitation and cooperation may be noted, affect alone does not confirm psychosis without evidence of altered perception or thought content.

C. Thought process: The client exhibits disorganized and paranoid thoughts, such as believing the clinic is a laboratory and the nurse is the devil. These delusions indicate impaired thought processes associated with psychosis.

D. Level of orientation: The client is able to state their name but not the date and misinterprets surroundings, demonstrating disorientation and impaired reality testing, which are consistent with psychosis.

E. Speech pattern: The notes do not specifically describe incoherence, flight of ideas, or pressured speech. While speech may reflect agitation, it is not explicitly documented as psychotic.

F. Physical appearance: The client appears disheveled with matted hair and stained clothing, reflecting neglect of self-care, which is often observed in clients experiencing psychosis.

A. Secure the tubing with adhesive tape to the lower abdomen: Properly securing the catheter tubing prevents tension on the catheter, reduces the risk of accidental dislodgment, and helps maintain a closed drainage system, which decreases the risk of infection.

B. Instruct the client to hold the drainage bag at waist height when ambulating: The drainage bag should always be kept below the level of the bladder to maintain proper urine flow and prevent backflow, which increases the risk of infection. Holding it at waist height is unsafe.

C. Coil the tubing on the bed above the collection bag: Placing tubing above the collection bag can allow urine to flow back toward the bladder, increasing the risk of urinary tract infection. Tubing should remain below bladder level.

D. Collect a sterile specimen from the urinary drainage bag: Sterile urine specimens should be obtained from a sampling port on the catheter using aseptic technique, not directly from the drainage bag, to avoid contamination.