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A nurse is assessing a 3-month-old patient who underwent a pyloromyotomy the previous day.
Which of the following findings would indicate a need for pain medication? Select all that apply.

Increased pulse rate.

Skin showing peripheral pallor.

Clenched fists.

Increased respiratory rate.

Restlessness.

Elevated temperature.

Answer and Explanation

Correct Answer : A,C,D,E,F

Choice A rationale

An increased pulse rate can be a sign of pain in infants. The heart rate increases as the body’s way of coping with the stress of pain.

Choice B rationale

Skin showing peripheral pallor is not typically associated with pain. It can be a sign of other conditions, such as anemia or shock, but it’s not a reliable indicator of pain.

Choice C rationale

Clenched fists can be a sign of pain in infants. It’s a common non-verbal cue that infants use to express discomfort.

Choice D rationale

An increased respiratory rate can also be a sign of pain. Like an increased heart rate, it’s a physiological response to stress.

Choice E rationale

Restlessness can be a sign of discomfort or pain in infants. Infants may squirm, fidget, or have trouble settling down when they’re in pain.

Choice F rationale

An elevated temperature is not typically a direct sign of pain, but it can indicate an underlying condition that might be causing pain, such as an infection.

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Correct Answer is ["C","D"]

Explanation

Based on the client’s current condition and the urgency of the interventions, the nurse should complete the following prescriptions first:

C) Apply oxygen 1 L/minute: The client’s oxygen saturation level needs to be kept above 94%. Given her difficulty in breathing and the fact that she is pale and sitting upright, it’s crucial to ensure she is receiving enough oxygen.
D) Give albuterol as ordered: Albuterol is a bronchodilator that can help relieve the client’s asthma symptoms. Since her symptoms did not resolve after taking her usual dose of albuterol, administering another dose as ordered can help improve her breathing.

A. Count and record the number of premature ventricular contractions per minute. B. Apply oxygen via nasal cannula and adjust to maintain oxygen saturation above 93%. C. Ensure troponin level assessments are scheduled every 3 to 6 hours for a series of three. D. Initiate dim lighting, lower alarm volumes, and control traffic in and out of the room area.

Correct Answer is B

Explanation

Choice A rationale

Counting and recording the number of premature ventricular contractions per minute is not the immediate priority for a patient experiencing symptoms of angina and shortness of breath. While it is important to monitor the patient’s heart rhythm, the immediate priority is to address the patient’s symptoms and stabilize their condition.

Choice B rationale

Applying oxygen via a nasal cannula and adjusting to maintain oxygen saturation above 93% is the immediate priority for a patient experiencing symptoms of angina and shortness of breath. Oxygen therapy can help to relieve the symptoms of angina and improve the patient’s oxygen saturation.

Choice C rationale

Ensuring troponin level assessments are scheduled every 3 to 6 hours for a series of three is important for diagnosing a heart attack, but it is not the immediate priority. The immediate priority is to address the patient’s symptoms and stabilize their condition.

Choice D rationale

Initiating dim lighting, lowering alarm volumes, and controlling traffic in and out of the room area can help to create a calm and quiet environment for the patient. However, this is not the immediate priority. The immediate priority is to address the patient’s symptoms and stabilize their condition.

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A nurse is assessing a 3-month-old patient who underwent a pyloromyotomy the previous day.Which of the following findings would indicate a need for pain medication? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Exhibits After the nurse assesses the client, the healthcare provider writes prescriptions. The nurse reviews the prescriptions. Which 2 prescriptions should the nurse complete first?

Correct Answer is ["C","D"]

Explanation

Correct Answer is B

Explanation

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A nurse is assessing a 3-month-old patient who underwent a pyloromyotomy the previous day.
Which of the following findings would indicate a need for pain medication? Select all that apply.