An elderly client with heart failure arrives at the emergency room due to nausea, vomiting, and anorexia.
Based on the client’s signs and symptoms, which piece of data from the medical history is most significant when planning this client’s care?

To calculate the infusion rate in gtt/min, we first need to calculate the infusion rate in mL/hr. The formula for this is:

Step 1: Calculate the infusion rate in mL/hr

Infusion rate (mL/hr)=Total time (hr)Total volume (mL) Substituting the given values: Infusion rate (mL/hr)=2 hr mL=250 mL/hr

Step 2: Convert the infusion rate from mL/hr to gtt/min Infusion rate (gtt/min)=60 min/hrInfusion rate (mL/hr)×Drop factor (gtt/mL).

Substituting the given values: Infusion rate (gtt/min)=60 min/hr mL/hr×10 gtt/mL ≈42 gtt/min Therefore, the nurse should regulate the infusion to approximately 42 gtt/min.

Choice A rationale

Determining when the last dose was administered is an important step in managing a client’s pain. However, it should not be the first action taken when a client requests the largest possible dose of pain medication. The nurse first needs to assess the client’s current level of pain to determine the appropriate intervention.

Choice B rationale

Reviewing the history for past use of recreational drugs is an important part of a comprehensive pain assessment. However, it should not be the first action taken when a client requests the largest possible dose of pain medication. The nurse first needs to assess the client’s current level of pain to determine the appropriate intervention.

Choice C rationale

Asking the client to rate the current level of pain using a pain scale should be the first action the nurse takes when a client requests the largest possible dose of pain medication. Pain is subjective and can only be accurately assessed by the person experiencing it. Using a pain scale helps the nurse quantify the client’s pain and guide appropriate interventions.

Choice D rationale

Encouraging the client to use diversional thoughts to manage pain can be a helpful non- pharmacological pain management strategy. However, it should not be the first action taken when a client requests the largest possible dose of pain medication. The nurse first needs to assess the client’s current level of pain to determine the appropriate intervention.