The nurse prioritizes which infant to administer pain medication to first? All have PRN (as needed) orders for pain medication.
A 12-month-old who is 2-days post-op cleft palate repair whose vital signs are within normal limits
A 6-month-old who is crying and becomes calm when held by a parent
An 8-month-old with legs drawn to chest and a temperature of 39.5 degrees C
A 4-month-old that has just returned from the recovery room
The Correct Answer is C
Choice A reason: This statement is false. A 12-month-old who is 2-days post-op cleft palate repair whose vital signs are within normal limits is not the priority for pain medication. This infant may have some pain from the surgery, but it is likely to be mild and manageable with non-pharmacological interventions, such as distraction, comfort, or oral care.
Choice B reason: This statement is false. A 6-month-old who is crying and becomes calm when held by a parent is not the priority for pain medication. This infant may have some pain from an unknown cause, but it is likely to be transient and responsive to non-pharmacological interventions, such as soothing, rocking, or cuddling.
Choice C reason: This statement is true. An 8-month-old with legs drawn to chest and a temperature of 39.5 degrees C is the priority for pain medication. This infant may have severe pain from an infection, such as appendicitis, meningitis, or urinary tract infection. This infant may also have signs of inflammation, such as fever, leukocytosis, or elevated C-reactive protein. This infant needs immediate pain relief and antibiotic therapy.
Choice D reason: This statement is false. A 4-month-old that has just returned from the recovery room is not the priority for pain medication. This infant may have some pain from the surgery, but it is likely to be moderate and controlled with pharmacological interventions, such as opioids, NSAIDs, or local anesthetics.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: This statement is false. Edema is a sign of fluid overload, not fluid deficit. Edema occurs when fluid accumulates in the interstitial space due to increased capillary hydrostatic pressure or decreased plasma oncotic pressure. Edema is more common in patients with heart failure, liver disease, or kidney disease¹.
Choice B reason: This statement is false. Skin turgor is a measure of skin elasticity and hydration. It can be affected by factors such as age, skin condition, and ambient temperature. Skin turgor is not a reliable indicator of fluid balance, as it can be normal in patients with mild to moderate hypovolemia².
Choice C reason: This statement is false. Urine output is a measure of kidney function and fluid excretion. It can be influenced by factors such as fluid intake, diuretics, hormones, and renal diseases. Urine output is not a sensitive indicator of fluid balance, as it can be normal or even increased in patients with hypovolemia due to compensatory mechanisms.
Choice D reason: This statement is true. Daily weight is a measure of body mass and fluid status. It can reflect changes in fluid balance more accurately than other methods, as long as the weight is measured at the same time, on the same scale, and with the same clothing each day. A decrease in weight can indicate fluid loss due to hypovolemia.
Correct Answer is C
Explanation
Choice A reason: Eating a piece of pizza is not a good option for the student. Pizza is a complex carbohydrate that contains fat and protein, which can delay the absorption of glucose and cause unpredictable blood sugar levels. The student needs a simple carbohydrate that can quickly raise her blood sugar level, such as glucose tablets, fruit juice, or candy.
Choice B reason: Taking an extra dose of rapid-acting insulin is a dangerous option for the student. Insulin lowers the blood sugar level, and the student already has symptoms of hypoglycemia (low blood sugar), such as headache, vision changes, and anxiety. Taking more insulin can worsen her condition and cause seizures, coma, or death.
Choice C reason: Eating 15 g of simple carbohydrates is the best option for the student. Simple carbohydrates are easily digested and absorbed into the bloodstream, and can raise the blood sugar level within 15 minutes. The student should eat 15 g of simple carbohydrates, such as four glucose tablets, half a cup of fruit juice, or three pieces of hard candy, and then check her blood sugar level if possible.
Choice D reason: Drinking some diet pop is not a helpful option for the student. Diet pop does not contain any sugar or calories, and will not affect the blood sugar level. The student needs a source of glucose to treat her hypoglycemia, and diet pop will not provide that.
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