A nurse is caring for a six-year-old child who had surgery that morning.
The child is awake and lying very still in bed.
What should the nurse do?

Use an “ouch” scale for pain assessment.

Encourage the child to request pain medication when needed.

Plan to administer pain medication if the child begins to cry.

Ask the child to rate their pain on a scale of 1 to 10.

Answer and Explanation

The Correct Answer is A

Choice A rationale

Using an “ouch” scale, such as the Wong-Baker FACES Pain Rating Scale, is appropriate for young children. It allows them to express their pain intensity in a way that is understandable and relatable to their age group.

Choice B rationale

Encouraging a six-year-old to request pain medication may not be effective, as they might not understand when they need it or might be reluctant to ask.

Choice C rationale

Waiting to administer pain medication until the child begins to cry can delay pain relief, leading to unnecessary discomfort and anxiety.

Choice D rationale

Asking a young child to rate their pain on a scale of 1 to 10 might be confusing and less effective than using a more child-friendly method like the “ouch” scale.

Nursing Test Bank

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Correct Answer is D

Explanation

Choice A rationale

Evidence of human fetal risk would categorize the drug as Category D or X, not Category B.

Choice B rationale

This statement aligns more with Category C drugs, where animal studies show adverse effects, but not Category B.

Choice C rationale

This describes Category A drugs, not Category B.

Choice D rationale

Category B drugs have shown no risk in animal studies but lack adequate human studies, fitting this description.

A. Maintain the patient’s confidentiality. B. Administer medications ordered immediately. C. Provide teaching about chronic renal failure. D. Call the admitting physician immediately.

Correct Answer is D

Explanation

Choice A rationale

While maintaining patient confidentiality is crucial, it does not address the immediate medical needs of the patient with chronic renal failure. The primary concern should be addressing the health implications of their condition and ensuring proper care coordination.

Choice B rationale

Administering medications ordered immediately is essential, but it is not the first priority without knowing the patient's current status and medical history. The nurse needs to ensure that the medications prescribed are appropriate for a patient with chronic renal failure.

Choice C rationale

Providing teaching about chronic renal failure is important for long-term management but is not the first priority upon admission. Immediate medical needs and communication with the care team take precedence in this acute care setting.

Choice D rationale

Calling the admitting physician immediately is the first priority. The primary care provider needs to be aware of the patient's diagnosis of chronic renal failure to adjust treatment plans accordingly. Immediate communication ensures that all healthcare professionals are on the same page regarding the patient's care. .

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A nurse is caring for a six-year-old child who had surgery that morning.The child is awake and lying very still in bed.What should the nurse do?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is instructing a pregnant patient concerning the potential risk to her fetus from a pregnancy category B drug.What would the nurse inform the patient?

Correct Answer is D

Explanation

The nurse admits a patient to the unit and learns the patient has recently been diagnosed with chronic renal failure but has not informed the primary care provider of this diagnosis.What is the nurse’s first priority?

Correct Answer is D

Explanation

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A nurse is caring for a six-year-old child who had surgery that morning.
The child is awake and lying very still in bed.
What should the nurse do?