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. Encourage prolonged dangling before ambulation: While dangling at the bedside can help prevent orthostatic hypotension, the client is already ambulating independently without reported dizziness or hypotension. Prolonged dangling is unnecessary and does not address the current issues of urinary discomfort and bowel cramping.

B. Encourage oral fluid intake: Adequate hydration helps maintain urine flow, prevent catheter obstruction, and support bowel function. Encouraging fluids also helps dilute urine, reducing bladder irritation and the risk of infection, which is especially important post-prostatectomy.

C. Assist the client with a sitz bath: A sitz bath can relieve perineal discomfort, reduce pain, and promote relaxation of the pelvic muscles. Given the client’s bladder fullness and postoperative cramping, this noninvasive intervention helps improve comfort and facilitate urination.

D. Irrigate indwelling catheter with 500 mL of fluid: Routine irrigation with such a large volume is not recommended and may cause trauma or introduce infection. Catheter irrigation should only be performed according to provider prescription and typically with small, prescribed amounts.

E. Administer an enema: The client reports only a single hard, painful bowel movement, and routine enema administration is not indicated. Enemas should be reserved for severe constipation or impaction, and inappropriate use can cause irritation or fluid shifts.

A. Positive clonus: Clonus indicates neuromuscular irritability and is a sign of worsening preeclampsia rather than therapeutic control. The presence of clonus suggests inadequate suppression of central nervous system excitability.

B. Respiratory rate 10/min: A respiratory rate of 10 per minute indicates respiratory depression, which is a sign of magnesium toxicity. This finding reflects an adverse effect rather than a therapeutic response.

C. Deep tendon reflexes 2+: Normal deep tendon reflexes indicate that magnesium levels are within the therapeutic range. This finding reflects effective seizure prophylaxis without evidence of magnesium toxicity.

D. Urinary output 20 mL/hr: Low urine output suggests impaired renal clearance of magnesium, increasing the risk for toxicity. Adequate urine output is needed to safely eliminate magnesium, so this finding is concerning rather than therapeutic.