A nurse is preparing to administer clindamycin by intermittent IV bolus over 30 minutes to a client who has a staphylococcal infection. Available is 300 mg clindamycin premixed in 50 mL 0.9% sodium chloride (NaCl). 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.)

Choice A reason:

The statement “Reposition the client a second time before assessing his respirations” is not appropriate in this scenario. If the client remains apneic after the initial airway repositioning, further repositioning is unlikely to be effective. Immediate action is required to determine the next steps in care.

Choice B reason:

The statement “Place a red tag on the client’s upper body and obtain immediate help from other personnel” is incorrect. A red tag is used for patients who require immediate medical attention and have a chance of survival with timely intervention. Since the client remains apneic despite airway repositioning, they are unlikely to survive without immediate advanced medical intervention, which may not be feasible in a mass casualty situation.

Choice C reason:

The statement “Place a black tag on the client’s upper body and attempt to help the next client in need” is correct. In a mass casualty incident, a black tag is used to indicate that a patient is deceased or expected to die due to the severity of their injuries and the lack of available resources to provide the necessary care. Since the client remains apneic with a weak pulse, they are unlikely to survive, and resources should be directed to those with a higher chance of survival.

Choice D reason:

The statement “Start CPR” is not the most appropriate action in this scenario. In a mass casualty situation, resources must be allocated to those who have the best chance of survival. Starting CPR on a client who remains apneic despite airway repositioning may not be the best use of limited resources, especially when other clients may need immediate attention and have a higher chance of survival.

Choice A: Pain Level
The client reports a pain level of 7 on a scale of 0 to 10. Postoperative pain is expected, but a pain level of 7 indicates severe pain that requires immediate attention. Effective pain management is crucial for postoperative recovery as unmanaged pain can lead to complications such as increased heart rate, elevated blood pressure, and delayed
healing. The nurse should assess the effectiveness of the current pain management plan and consider administering additional analgesics or adjusting the pain management strategy. Pain should be reassessed frequently to ensure the client is comfortable and to prevent complications associated with severe pain.

Choice B: Blood Pressure
The client’s blood pressure is 138/72 mmHg, which is within the normal range for adults (systolic 90-120 mmHg and diastolic 60-80 mmHg). While slightly elevated, this blood pressure reading does not require immediate follow-up in the context of postoperative care unless there are other symptoms indicating a hypertensive crisis or other cardiovascular issues. It is important to monitor blood pressure regularly, but in this scenario, it is not one of the critical findings that require immediate intervention.

Choice C: Lung Sounds
Crackles heard upon auscultation in the posterior lungs and the client being dyspneic are significant findings that require immediate follow-up. Crackles can indicate fluid accumulation in the lungs, which may be a sign of pulmonary edema or pneumonia. Dyspnea, or difficulty breathing, further supports the need for urgent assessment and intervention. The nurse should perform a thorough respiratory assessment, monitor oxygen saturation levels, and notify the healthcare provider. Interventions may include administering supplemental oxygen, positioning the client to improve ventilation, and possibly initiating diuretic therapy if fluid overload is suspected.

Choice D: Incision Site
The incision site has purulent drainage, redness, and warmth, which are classic signs of infection. Postoperative infections can lead to serious complications, including sepsis if not promptly addressed. The nurse should assess the incision site for additional signs of infection, such as increased swelling, foul odor, or increased pain. The healthcare provider should be notified immediately to initiate appropriate interventions, which may include wound cultures, antibiotics, and possibly surgical intervention to manage the infection. Monitoring the client’s temperature and other vital signs is also essential to detect systemic infection early.

Choice E: Pedal Pulses
The client’s pedal pulses are +2 bilaterally, which is considered normal. Pedal pulses are assessed to evaluate peripheral circulation, and a +2 rating indicates normal pulse strength. There is no immediate concern regarding the client’s peripheral circulation based on this finding. However, it is important to continue monitoring peripheral pulses as part of routine postoperative care to ensure there are no changes that could indicate vascular complications.