A nurse is evaluating an 8-month-old infant's pain level following the administration of hydrocodone. Which of the following pain scales would the nurse use?

Oucher scale

Visual Analog

FLACC scale

FACES pain scale

Answer and Explanation

The Correct Answer is C

A) Oucher scale: The Oucher scale is a pain assessment tool that is appropriate for children ages 3 to 12 years. It uses a series of photos depicting facial expressions that range from no pain to extreme pain. While useful for older children, it is not the most appropriate choice for an 8-month-old infant.

B) Visual Analog scale: The Visual Analog scale is typically used for children and adults who are able to understand and use numerical ratings or visual representations of pain. Since an 8-month-old infant is unable to verbally communicate or use this scale, it would not be suitable for evaluating their pain.

C) FLACC scale: The FLACC scale (Face, Legs, Activity, Cry, Consolability) is designed for infants and young children who are unable to verbally communicate their pain. It is ideal for assessing the pain levels of infants, as it evaluates observable behaviors like facial expressions, leg movement, and crying, which are indicators of pain in nonverbal children.

D) FACES pain scale: The FACES pain scale is typically used for children as young as 3 years old, but it requires the child to be able to identify and select facial expressions that correspond to their pain. An 8-month-old infant would not be able to engage with this scale, as it requires some cognitive development and understanding of emotional expressions.

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Correct Answer is C

Explanation

A) pH 7.36 (7.35 to 7.45), PaCO2 38 mm Hg (35 to 45 mmHg), HCO3 25 mEq/L (22 to 26 mEq/L): This is a normal set of arterial blood gas (ABG) values, with a pH within normal range, a normal PaCO2, and a normal HCO3. It does not suggest metabolic alkalosis.

B) pH 7.48 (7.35 to 7.45), PaCO2 32 mm Hg (35 to 45 mm Hg), HCO3 24 mEq/L (22 to 26 mEq/L): Although the pH is elevated, indicating alkalosis, the PaCO2 is slightly low, and the bicarbonate (HCO3) is within the normal range. This set of values does not indicate metabolic alkalosis, but could indicate respiratory alkalosis or compensated alkalosis.

C) pH 7.46 (7.35 to 7.45), PaCO2 36 mm Hg (35 to 45 mm Hg), HCO3 29 mEq/L (22 to 26 mEq/L): This is consistent with metabolic alkalosis. The elevated pH (alkalosis) combined with an increased bicarbonate level (HCO3 > 26 mEq/L) and a normal PaCO2 suggests metabolic alkalosis, as the kidneys retain bicarbonate to compensate for the condition.

D) pH 7.26 (7.35 to 7.45), PaCO2 35 mm Hg (35 to 45 mm Hg), HCO3 18 mEq/L (22 to 26 mEq/L): This set of values indicates acidosis, not alkalosis. The pH is low, indicating acidosis, and the bicarbonate (HCO3) is also low, which suggests metabolic acidosis. The PaCO2 is normal, which further supports a metabolic origin of the acidosis.

A. Wait 1 min between 1 suctioning attempts B. Apply intermittent suction for 30 seconds C. Insert the catheter 10 cm (4 in.) D. Apply suction while inserting the catheter.

Correct Answer is C

Explanation

A) Wait 1 min between suctioning attempts: The nurse should wait 20 to 30 seconds between suctioning attempts, not a full minute. Waiting too long between attempts can cause the patient unnecessary distress. The goal is to allow for oxygenation and recovery of the airway in between suctioning attempts.

B) Apply intermittent suction for 30 seconds: Suctioning should be limited to 10 to 15 seconds at a time to prevent hypoxia and damage to the mucous membranes. Applying suction for 30 seconds could lead to complications such as hypoxia, mucosal trauma, and increased risk of infection.

C) Insert the catheter 10 cm (4 in.): This is the correct technique. For an adult client, the catheter should be inserted 10 cm (4 inches) into the airway. Inserting the catheter too far can cause trauma to the airway, while inserting it too shallow may not effectively clear secretions.

D) Apply suction while inserting the catheter: Suction should not be applied while inserting the catheter. Suctioning should only be applied while withdrawing the catheter, not while inserting it, to prevent mucosal trauma and to ensure effective clearance of secretions. Suctioning during insertion could damage the airway and increase discomfort for the client.

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A nurse is evaluating an 8-month-old infant's pain level following the administration of hydrocodone. Which of the following pain scales would the nurse use?

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