Which nursing diagnosis takes priority for a client who is receiving chemotherapy treatment for cancer?

To explain why, we need to use the formula for calculating the drip rate in drops per minute (dpm):

Volume of IV fluid (mL) x Drop Factor (drops/mL) / Time to run (h) x 60 (min/h) = Drip Rate (dpm)

In this question, the volume of IV fluid is one liter, which is equivalent to 1000 mL. The drop factor is 15 drops per mL, as given by the tubing.

The time to run is six hours, as ordered by the physician. Plugging these values into the formula, we get:

1000 mL x 15 drops/mL / 6 h x 60 min/h = 84 dpm

Therefore, the nurse should regulate the infusion to deliver 84 drops per minute.

Choice A is wrong because it gives a drip rate of 42 drops per minute, which is half of the correct answer.

This would result in delivering only 500 mL of normal saline in six hours, instead of one liter.

Choice C is wrong because it gives a drip rate of 100 drops per minute, which is more than the correct answer.

This would result in delivering 1.43 liters of normal saline in six hours, instead of one liter.

Choice D is wrong because it gives a drip rate of 166 drops per minute, which is almost double the correct answer.

This would result in delivering 1.99 liters of normal saline in six hours, instead of one liter.

Normal saline is a solution of 0.9% sodium chloride in water, which has the same osmolarity as blood plasma.

It is used to treat dehydration, shock, blood loss, and other conditions that require fluid replacement.

The normal range of sodium in blood is 135-145 mEq/L.

Using an automatic BP cuff with a shivering client with a history of an irregular heart rate can result in inaccurate and low readings.

This is because shivering can interfere with the cuff inflation and deflation, and an irregular heart rate can affect the accuracy of the device.

The nurse should intervene and use a manual BP cuff with a stethoscope instead.

Choice B is wrong because pulling the client’s ear pinna backward, up and out to obtain a tympanic membrane temperature is the correct technique for adults and older children. This helps to straighten the ear canal and allow the light to reflect on the tympanic membrane, which shares the same vascular artery as the hypothalamus.

Choice C is wrong because counting the client’s radial pulse who is supine with the forearm straight alongside the body is an appropriate method.

The radial pulse can be easily palpated at the wrist, and the supine position and straight forearm do not affect the pulse rate.

Choice D is wrong because counting the respirations for one full minute for a client with tachypnea is a recommended practice.

Tachypnea means rapid breathing, and counting for one full minute can ensure accuracy and detect any variations in the respiratory pattern.