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 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.

A. Ask the patient about home insulin doses B. Administer IV potassium supplements C. Place the patient on a cardiac monitor D. Start an insulin infusion at 0.1 units/kg/h

Correct Answer is B

Explanation

Choice A reason: This statement is false. Asking the patient about home insulin doses is not the action that the nurse should take first. Insulin is a hormone that lowers the blood glucose level and can also lower the blood potassium level by driving potassium into the cells. However, this is not the primary cause of hypokalemia, or low blood potassium level, which can be due to other factors such as diuretics, vomiting, diarrhea, or alkalosis.

Choice B reason: This statement is true. Administering IV potassium supplements is the action that the nurse should take first. Potassium is an electrolyte that is essential for the normal function of the heart, muscles, and nerves. Hypokalemia can cause cardiac arrhythmias, muscle weakness, and paralysis. IV potassium supplements can restore the blood potassium level and prevent life-threatening complications.

Choice C reason: This statement is false. Placing the patient on a cardiac monitor is not the action that the nurse should take first. A cardiac monitor is a device that records the electrical activity of the heart and can detect any abnormal rhythms or conduction problems. It is a useful tool for monitoring the patient's cardiac status, but it does not treat the underlying cause of hypokalemia.

Choice D reason: This statement is false. Starting an insulin infusion at 0.1 units/kg/h is not the action that the nurse should take first. Insulin infusion is a method of delivering insulin continuously through a pump or a catheter. It is used for patients with diabetes who need tight glucose control. It can also lower the blood potassium level by driving potassium into the cells. However, this is not t

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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

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Correct Answer is C

Explanation

A client has a serum potassium level of 2.9 mEq/L. Which action prescribed by the health care provider should the nurse take first?

Correct Answer is B

Explanation

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