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

Answer and Explanation

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.

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Correct Answer is A

Explanation

Choice A reason: This statement is true. Kayexalate is a medication that binds to potassium in the colon and exchanges it for sodium, thereby lowering the blood potassium level. It also has a laxative effect, which helps to eliminate the excess potassium in the stool.

Choice B reason: This statement is false. Kayexalate does not have a diuretic effect, which means it does not increase urine output or fluid loss. Diuretics are medications that act on the kidneys and help to remove excess fluid and sodium from the body.

Choice C reason: This statement is false. Kayexalate does not lower the blood sodium level, but rather increases it. This is because it exchanges potassium for sodium in the colon, which adds more sodium to the bloodstream.

Choice D reason: This statement is false. Kayexalate does not cause diarrhea, but rather a laxative effect, which means it stimulates bowel movements and softens the stool. Diarrhea is a condition where the stool is watery and frequent, and can cause dehydration and electrolyte imbalance.

A. Administer IV morphine sulfate 4 mg every 2 hours PRN B. Dextrose 5% in 0.9% sodium chloride, continuous infusion C. Infuse 5% dextrose in water at 125 mL/hr D. Neurologic assessment Q2 hours

Correct Answer is C

Explanation

Choice A reason: This statement is false. IV morphine sulfate is a pain medication that can be given as needed to the postoperative patient. It does not affect the serum sodium level.

Choice B reason: This statement is false. Dextrose 5% in 0.9% sodium chloride is a hypertonic solution that can be used to treat hyponatremia, or low serum sodium level. It provides both glucose and sodium to the patient.

Choice C reason: This statement is true. 5% dextrose in water is a hypotonic solution that can cause further dilution of the serum sodium level. It can worsen the hyponatremia and increase the risk of cerebral edema and seizures.

Choice D reason: This statement is false. Neurologic assessment Q2 hours is a necessary intervention for a patient with hyponatremia, as it can monitor for signs of neurologic deterioration such as confusion, lethargy, or coma.

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The nurse prioritizes which infant to administer pain medication to first? All have PRN (as needed) orders for pain medication.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is administering Kayexalate to a client. The nurse explains that this medication will:

Correct Answer is A

Explanation

A postoperative patient who had surgery for a perforated gastric ulcer has been receiving nasogastric suction for 3 days. The patient now has a serum sodium level of 127 mEq/L (127 mmol/L). Which prescribed therapy should the nurse question?

Correct Answer is C

Explanation

The nurse is caring for a 10-month old client with dehydration. What method would the nurse use to measure urine output?

A postoperative patient who had surgery for a perforated gastric ulcer has been receiving nasogastric suction for 3 days. The patient now has a serum sodium level of 127 mEq/L (127 mmol/L). Which prescribed therapy should the nurse question?

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The nurse is caring for an infant who weighs 16 kg. Calculate the daily maintenance fluid requirement for this child. Round to the nearest whole number.

A client is taking furosemide (Lasix) for management of mild hypertension. The nurse knows to assess laboratory results for a side effect of this diuretic. Select the lab value that matches a common side effect of this medication.

For the client mentioned above (nausea/vomiting, Salmonella infection), the nurse anticipates an order for which of the following IV fluids?

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