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)

Rationale for correct choices:

• Emotional lability: The client demonstrates rapid and intense shifts in mood, such as being angry and hostile toward staff, then later praising the nurse excessively. This instability in affect is characteristic of borderline personality disorder (BPD). Emotional lability often leads to interpersonal conflicts and impulsive behaviors, which were observed in aggressive interactions with peers. Recognizing these shifts is essential for guiding therapeutic interventions.

• Fear of abandonment: Clients with BPD frequently experience intense fear of real or perceived abandonment, influencing their relationships and behaviors. The client’s alternating hostility and praise toward the nurse may reflect anxiety over potential rejection or inconsistent attachment. Identifying this fear helps the nurse implement consistent, supportive care while maintaining professional boundaries.

Rationale for incorrect choices:

• Elevated body temperature: There is no evidence of fever or infection in the client. Elevated temperature is not a feature of BPD. It reflects physiological issues unrelated to emotional or behavioral manifestations.

• Tactile hallucinations: The client has not reported or demonstrated perceptual disturbances such as hallucinations. Psychotic symptoms are not part of the core diagnostic features of BPD. Monitoring for hallucinations is unnecessary unless indicated by comorbid conditions.

• Increased heart rate: While heart rate may increase transiently during stress or agitation, it is a physiological response and not a defining characteristic of BPD. Emotional lability and interpersonal fears more accurately reflect the disorder’s manifestations.

A. Respiratory rate: A respiratory rate of 30 breaths per minute indicates significant respiratory distress. Labored breathing combined with crackles and wheezes suggests impaired gas exchange and possible lower respiratory infection requiring urgent intervention.

B. Oxygen saturation level: An oxygen saturation of 89% on room air reflects hypoxemia. Reduced oxygen levels place the client at risk for tissue hypoxia and worsening respiratory failure, making prompt follow-up and oxygen therapy necessary.

C. Chronic health condition: A history of smoking, Parkinson’s disease, and anxiety increases overall health risk but does not explain the acute deterioration. Chronic conditions provide context but are not the immediate priority compared with current unstable findings.

D. Tremors: Hand tremors are consistent with Parkinson’s disease and may also be worsened by anxiety or illness. Tremors alone do not pose an immediate life-threatening risk in this situation.

E. Current level of consciousness: Orientation only to self and failure to follow commands suggest acute changes in mental status. Altered cognition in an older adult with fever and hypoxia may indicate delirium or worsening infection and requires immediate evaluation.

F. Heart rate: A heart rate of 104 beats per minute indicates mild tachycardia, likely related to fever or hypoxia. Although important to monitor, it is less immediately threatening than hypoxemia, tachypnea, and altered mental status.