A nurse is preparing to administer lidocaine 2 mg/min by continuous IV infusion to a client. The amount available is lidocaine 400 mg in 100 mL of dextrose 5% in water. 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. Dilated appearance of the AV site: A dilated appearance of the AV site is not necessarily a complication. Some dilation may be expected as the graft matures. However, significant or sudden dilation could indicate an issue, such as stenosis or a developing clot, which should be assessed further.

B. Absence of a bruit: The absence of a bruit over an arteriovenous graft is a sign of a potential complication, such as thrombosis or a blockage in the graft. The bruit indicates proper blood flow through the graft. Its absence suggests a lack of blood flow, which requires immediate attention.

C. 2+ left radial pulse: A 2+ pulse is considered normal and indicates adequate peripheral circulation. It does not suggest a complication related to the AV graft.

D. Presence of a palpable thrill: A palpable thrill is typically a normal finding when assessing an AV graft. It is the vibration felt over the graft site due to blood flow and indicates that the graft is functioning properly.

Rationale for Correct Choices:

• Instruct the client to rise slowly from a sitting position: The client is showing signs of orthostatic hypotension, with a drop in blood pressure when changing positions. Providing instructions to rise slowly helps prevent dizziness and potential falls, especially in the presence of anemia-related fatigue and reduced oxygen delivery.
• Evaluate a stool sample for occult blood: The client has anemia (Hgb 8 g/dL, Hct 24%) and is taking naproxen, a nonsteroidal anti-inflammatory drug (NSAID) known to cause gastrointestinal bleeding. Occult GI blood loss is a common cause of iron deficiency anemia in such clients. Identifying hidden bleeding is a priority to determine the cause of anemia.

Rationale for Incorrect Choices:

• Draw a blood sample for arterial blood gases: There is no evidence of acute respiratory distress or hypoxemia requiring blood gas analysis. The client’s oxygen saturation is 94% on room air, and breath sounds are clear, making this action unnecessary at this time.
• Perform a 12-lead ECG: Although the client has tachycardia (HR 108/min), this is likely a compensatory response to anemia. Without chest pain or other signs of cardiac compromise, a 12-lead ECG is not the most immediate action.
• Administer an inhaled bronchodilator: The client reports dyspnea with exertion, but there is no indication of bronchospasm or wheezing. Breath sounds are clear bilaterally, so a bronchodilator is not indicated and would not address the underlying issue of anemia.