A nurse is caring for an 18-month-old infant who is 12 hr postoperative following a myringotomy. Which of the following pain rating scales should the nurse use?
Poker Chip Tool
Color tool
Numeric scale
FLACC scale
The Correct Answer is D
A. The Poker Chip Tool is used to assess pain in children who can understand the concept of "a few" to "lots" of pain, typically in older children. It is not appropriate for infants or toddlers.
B. The Color tool is used for children who can associate color with pain intensity, but it is generally for older children who can understand this system, not for infants.
C. The Numeric scale is designed for children who are old enough to understand and use numbers (typically older than 8 years). An 18-month-old would not be able to understand this scale.
D. The FLACC (Face, Legs, Activity, Cry, Consolability) scale is specifically designed to assess pain in infants and nonverbal children. It uses behavioral indicators to rate pain intensity and is appropriate for an 18-month-old toddler.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Passive range-of-motion exercises should be performed to prevent complications like contractures, but they should be done as ordered by the provider, not automatically every 2 hours.
B. Applying protective padding to the end of the pin sites helps prevent pressure injuries and irritation, which is a key part of maintaining skin integrity and preventing infection.
C. There is no indication that fiber intake should be reduced. In fact, a high-fiber diet is encouraged to prevent constipation, which is a common complication for immobile patients.
D. The traction weights should not be lifted off the floor, as this could interfere with the traction setup and the healing process. Traction should be maintained properly to align and stabilize the fracture.
Correct Answer is B
Explanation
A. Crushing sustained-release tablets is not recommended because it can alter the medication's intended effect, releasing it all at once, which can be dangerous for the child.
B. Allowing medications to flow into the tube by gravity is the correct method. It ensures the medication is delivered slowly and effectively, preventing the tube from clogging and ensuring proper absorption.
C. Flushing the tube with 2 mL of sterile water is insufficient after all medications are administered. Typically, the tube should be flushed with 15-30 mL of water before and after medication administration to ensure patency.
D. Mixing all medications together is not recommended because different medications may have incompatible properties, and mixing them could alter their effectiveness or cause adverse reactions. Each medication should be administered separately.
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