A nurse is caring for a 4-year-old child following an orthopaedic procedure. When assessing the child for pain, which of the following pain scales should the nurse use?

FACES.

Word-graphic.

Numeric.

CRIES.

Answer and Explanation

The Correct Answer is A

The FACES pain scale is a self-report tool that uses six facial expressions to indicate different levels of pain. It is suitable for children aged 3 to 13 years who can match their pain to a face. The nurse should use this scale to assess the pain of a 4-year-old child following an orthopaedic procedure.

Choice B. Word-graphic is wrong because it is a pain scale that uses words and pictures to describe pain intensity.

It is suitable for children aged 8 to 17 years who can read and understand words.

Choice C. Numeric is wrong because it is a pain scale that uses numbers from 0 to 10 to rate pain intensity. It is suitable for children aged 5 years and older who can understand numbers and concepts of more or less.

Choice D. CRIES is wrong because it is a pain scale that uses five behavioural indicators (crying, requiring increased oxygen, increased vital signs, expression, and sleeplessness) to measure pain in neonates.

It is suitable for infants aged 0 to 6 months who cannot communicate verbally.

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Correct Answer is B

Explanation

This is because fever is a common sign of an acute infusion reaction that can occur when receiving IV amphotericin B. An acute infusion reaction is caused by the release of pro-inflammatory cytokines from the fungal cell wall disruption by amphotericin B. It usually occurs within the first hour of infusion and can be prevented by administering pre-medications such as antipyretics, antihistamines, or corticosteroids.

Choice A. Pedal edema is wrong because it is not a typical sign of an acute infusion reaction.

Pedal edema may indicate fluid overload, heart failure, or renal impairment, which are not directly related to amphotericin B infusion.

Choice C. Dry cough is wrong because it is not a typical sign of an acute infusion reaction.

Dry cough may indicate an allergic reaction, pulmonary infection, or interstitial lung disease, which are not directly related to amphotericin B infusion. Choice D. Hyperglycemia is wrong because it is not a typical sign of an acute infusion reaction.

Hyperglycemia may indicate diabetes mellitus, steroid use, or stress response, which are not directly related to amphotericin B infusion.

A. Limit foods containing tyramine. B. Decrease your daily sodium intake. C. Take this medication 2 hours before a meal. D. Report swelling of the feet to your provider.

Correct Answer is D

Explanation

This is because swelling of the feet can be a sign of lithium toxicity, which is a serious condition that can occur when the level of lithium in the blood is too high. Lithium toxicity can cause confusion, irregular heartbeat, muscle weakness, and kidney problems. Therefore, the client should report any signs of lithium toxicity to their provider as soon as possible.

Choice A is wrong because limiting foods containing tyramine is not necessary for clients taking lithium. Tyramine is a substance found in some foods that can interact with certain antidepressants called monoamine oxidase inhibitors (MAOIs), but not with lithium.

Choice B is wrong because decreasing the daily sodium intake can actually increase the risk of lithium toxicity.

Sodium helps to regulate the amount of lithium in the body, so if the sodium level is low, the lithium level can rise too high.

The client should maintain a normal sodium intake and drink enough fluids while taking lithium.

Choice C is wrong because taking this medication 2 hours before a meal is not required for clients taking lithium.

Lithium can be taken with or without food, but it should be taken at the same time each day to keep a steady level in the blood.

Taking lithium 2 hours before a meal may cause stomach upset, which is a common side effect of lithium.

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A nurse is caring for a 4-year-old child following an orthopaedic procedure. When assessing the child for pain, which of the following pain scales should the nurse use?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is monitoring for an infusion reaction for a client who is receiving a dose of IV amphotericin B. Which of the following findings should indicate to the nurse that the client is experiencing an acute infusion reaction?

Correct Answer is B

Explanation

A nurse is providing teaching to a client who has a new prescription for lithium carbonate. Which of the following instructions should the nurse include?

Correct Answer is D

Explanation

A nurse is assessing a client who is receiving intravenous therapy. The nurse should identify which of the following findings as a manifestation of fluid volume excess?

A nurse is preparing to administer the initial dose of penicillin G IM to a client. The nurse should monitor for which of the following as an indication of an allergic reaction following the injection?

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A nurse recently administered filgrastim intravenously to a client who has cancer and is receiving cytotoxic chemotherapy. For which of the following data, discovered after the medication was administered, should the nurse file an incident report?

A nurse is planning care for a client who is receiving morphine via continuous epidural infusion. The nurse should monitor the client for which of the following adverse effects?

A nurse is preparing to administer subcutaneous heparin to a client. Which of the following actions should the nurse take?

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