A patient is unresponsive to verbal stimuli and exhibits an altered level of consciousness.

Which method should the nurse use to elicit a response from a painful stimulus?

Press down on the orbital area of the eye.

Pinch the trapezius muscle.

Use a 25 gauge needle.

Elicit a reflex with a reflex hammer.

Answer and Explanation

The Correct Answer is B

Choice A rationale
Pressing down on the orbital area of the eye is not typically used as it can cause injury to the eye.
Choice B rationale
Pinching the trapezius muscle is a common method used to elicit a response from a painful stimulus in an unresponsive patient. It is considered safe and effective.
Choice C rationale
Using a 25 gauge needle to elicit a response is not typically recommended as it can cause unnecessary harm to the patient.
Choice D rationale
Eliciting a reflex with a reflex hammer is not typically used to assess responsiveness to painful stimuli. Reflex hammers are primarily used to test reflexes, not responsiveness.

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Correct Answer is A

Explanation

Choice A rationale
During the fluid resuscitation phase of burn management, the primary goal is to restore circulating volume and preserve vital organ and tissue perfusion. One of the most effective methods for assessing the results of fluid resuscitation is monitoring urine output. A urine output greater than 0.5 mL/kg/hr is generally considered an indicator of adequate fluid resuscitation.
Choice B rationale
While clear bilateral breath sounds are an important part of overall patient assessment, they are not the best method for assessing the results of fluid resuscitation in burn management.
Choice C rationale
Serum hemoglobin is not the best indicator for assessing the results of fluid resuscitation in burn management. While it can provide information about the patient’s overall health and blood volume, it does not directly reflect the adequacy of fluid resuscitation.
Choice D rationale
A heart rate of 122/min could indicate a response to pain, anxiety, or inadequate fluid resuscitation. However, it is not the best method for assessing the results of fluid resuscitation in burn management.

A. Inject the medication into the abdomen above the level of the iliac crest. B. Use a 1-inch needle to inject the medication. C. Use a 22-gauge needle to inject the medication. D. Massage the injection site after administration of the medication.

Correct Answer is A

Explanation

Choice A rationale
The abdomen is a common site for subcutaneous injections because it allows for consistent absorption. The area above the iliac crest is often used because it is easy to access and usually has enough subcutaneous tissue for the injection.
Choice B rationale
A 1-inch needle is typically too long for a subcutaneous injection. A shorter needle (usually 1/2 to 5/8 inch) is usually used to ensure the medication is delivered to the subcutaneous tissue.
Choice C rationale
A 22-gauge needle is typically too large for a subcutaneous injection. Smaller gauge needles (usually 25-27 gauge) are usually used for subcutaneous injections.
Choice D rationale
Massaging the injection site after administration of heparin is not recommended. It can cause the medication to be absorbed too quickly and can also lead to bruising.

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A patient is unresponsive to verbal stimuli and exhibits an altered level of consciousness. Which method should the nurse use to elicit a response from a painful stimulus?

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A patient is unresponsive to verbal stimuli and exhibits an altered level of consciousness.

Which method should the nurse use to elicit a response from a painful stimulus?