The nurse is administering multiple prescribed vaccines to a toddler. Which strategy should the nurse prioritize to reduce the duration of pain?

Physical soothing.

Verbal reassurance.

Simultaneous injections.

Supine positioning.

Answer and Explanation

The Correct Answer is C

A)   Incorrect- While physical soothing can help comfort the child after the injections, it may not significantly reduce the duration of pain during the injections themselves.
B)   Incorrect- Verbal reassurance is important to provide a calming environment, but it may not directly reduce the duration of pain during the injections.
C)   Correct- Administering vaccines can be distressing for toddlers due to the pain associated with injections. To reduce the duration of pain and minimize the overall discomfort, the nurse should prioritize the strategy of simultaneous injections. This involves administering multiple vaccines at the same time rather than spacing them out. The rationale behind this approach is that the child experiences the discomfort of the injections only once, which can help reduce their overall distress and anxiety.
D)   Incorrect- The positioning of the child may not have a direct impact on the duration of pain during injections. However, choosing an appropriate position for comfort is still important.

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Correct Answer is D

Explanation

A) Incorrect - Initiating continuous dopamine infusion is not a priority in this situation. The client's low blood pressure and electrolyte imbalances require more immediate attention.
B) Incorrect - Administering promethazine addresses symptoms like nausea and vomiting, but it doesn't address the primary issue of hypovolemia and low blood pressure.
C) Incorrect - Administering potassium chloride without addressing the fluid deficit can be dangerous and may lead to further electrolyte imbalances.
D) Correct- The client's vital signs and laboratory results indicate hypovolemia (low blood pressure, low sodium, and low potassium). The immediate priority is to address the fluid deficit and correct the electrolyte imbalances. Administering a bolus of 0.9% sodium chloride (normal saline) will help increase intravascular volume and improve blood pressure, as well as correct the electrolyte imbalances to some extent.

A. Palpate all peripheral pulse points for volume and strength. B. Monitor the amount of drainage from the client's incision. C. Observe both lower extremities for redness and swelling. D. Evaluate the client's ability to use an incentive spirometer.

Correct Answer is C

Explanation

The correct answer is choice C. Observe both lower extremities for redness and swelling.

Choice A rationale:

Palpating all peripheral pulse points for volume and strength is important for assessing circulation, but it does not directly evaluate the effectiveness of intermittent pneumatic compression (IPC) devices.IPC devices are primarily used to prevent deep vein thrombosis (DVT) and improve venous return, so monitoring for signs of DVT is more relevant.

Choice B rationale:

Monitoring the amount of drainage from the client’s incision is crucial for assessing wound healing and detecting potential infections, but it is not related to the effectiveness of IPC devices.

Choice C rationale:

Observing both lower extremities for redness and swelling is the most important assessment for evaluating the effectiveness of IPC devices. Redness and swelling can be signs of DVT, which IPC devices are designed to prevent.Therefore, this assessment directly measures whether the devices are functioning as intended.

Choice D rationale:

Evaluating the client’s ability to use an incentive spirometer is important for preventing postoperative pulmonary complications, but it does not assess the effectiveness of IPC devices.

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The nurse is administering multiple prescribed vaccines to a toddler. Which strategy should the nurse prioritize to reduce the duration of pain?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is D

Explanation

In evaluating the effectiveness of a postoperative client's intermittent pneumatic compression devices, which assessment is most important for the nurse to complete?

Correct Answer is C

Explanation

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