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. Difficulty swallowing: Difficulty swallowing is more commonly associated with cranial nerve involvement, neuromuscular disorders, or medication side effects rather than pain perception. It does not reliably reflect inadequate pain control following a spinal epidural. Difficulty swallowing would prompt evaluation of airway or neurologic status rather than pain relief.

B. Urinary retention: Urinary retention is a known effect of spinal or epidural anesthesia due to temporary blockade of sacral nerves. It reflects autonomic nervous system involvement rather than the client’s pain level. Retention can occur even when pain is adequately managed.

C. Restlessness: Restlessness is a common behavioral indicator of unrelieved pain, especially when pain persists despite treatment. Clients may appear unable to relax, frequently change positions, or seem agitated when discomfort is not controlled. This finding suggests the need for reassessment of pain management effectiveness.

D. Constipation: Constipation is associated with opioid use, reduced mobility, or decreased gastrointestinal motility rather than uncontrolled pain. It develops over time and is not an acute indicator of ineffective pain relief. It would prompt bowel management rather than pain reassessment.

A. Attach a blood pressure cuff to the client's upper arm: A blood pressure cuff is not required for obtaining a 12-lead ECG. Its use does not contribute to the quality of the ECG tracing and is unnecessary during this procedure.

B. Tell the client to expect a mild stinging sensation during the test: A 12-lead ECG is noninvasive and painless. Electrodes are placed on the skin with adhesive gel or pads, and clients typically feel no stinging. Providing accurate expectations helps reduce anxiety.

C. Assist the client to the orthopneic position: The orthopneic position is used to ease breathing in clients with respiratory distress. For a 12-lead ECG, the client should lie supine to ensure proper electrode placement and accurate readings.

D. Instruct the client to remain as still as possible during the recording: Movement can create artifacts on the ECG tracing, making interpretation difficult. Remaining still ensures accurate detection of cardiac electrical activity and reliable diagnostic results.