A nurse is collecting data from an 18-month-old toddler who is postoperative. Which of the following rating scales should the nurse use to identify the toddler's pain level?
Color tool
FACES
Visual analog
FLACC
The Correct Answer is D
Choice A reason:
The color tool is not a pain assessment tool; it is used to assess oxygen saturation levels.
Choice B reason:
The FACES scale is commonly used for children who are 3 years of age and older, but it may not be suitable for an 18-month-old toddler who may have limited ability to express pain through facial expressions.
Choice C reason:
The visual analog scale is typically used for older children and adults. It may not be effective for assessing pain in an 18-month-old toddler.
Choice D reason:
The FLACC scale (Face, Legs, Activity, Cry, Consolability) is a validated pain assessment tool for young children, including toddlers. It evaluates specific behaviors related to pain, making it suitable for this age group.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["2.5"]
Explanation
- Convert the infant's weight from pounds to kilograms: 22 Ib / 2.2 = 10 kg
- Calculate the daily dose of azithromycin: 10 mg/kg/day x 10 kg = 100 mg/day
- Calculate the volume of azithromycin oral suspension needed: 100 mg/day / (200 mg/5 mL) = 2.5 mL/day
- Round the answer to the nearest tenth: 2.5 mL/day
- The nurse should plan to administer 2.5 mL of azithromycin oral suspension to the infant.
Correct Answer is D
Explanation
Choice A reason:
A temperature of 37.7° C (99.9° F) is slightly elevated but not a cause for immediate concern after immunization. It can be a normal response.
Choice B reason:
Redness at the injection site is a common and expected reaction after immunization. It does not require immediate intervention.
Choice C reason:
Prolonged crying can occur after immunization, but it is not a priority over a potential allergic reaction indicated by hives.
Choice D reason:
Hives on the child's neck indicate a potential allergic reaction to the immunization. This is a priority finding and requires immediate attention from the nurse.
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