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

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.

Choice A reason: This statement is true. This client may have a high tolerance to opioids and require a higher dose for pain control, as tolerance is a condition where the body becomes less responsive to the effects of a drug over time, and needs more of the drug to achieve the same effect. Tolerance can develop from chronic or repeated use of opioids, and can vary from person to person. The nurse should assess the client's pain level, history of opioid use, and response to the medication, and adjust the dose accordingly.

Choice B reason: This statement is false. Clients with a history of opioid abuse should not be denied an opioid analgesic, as opioids are effective and appropriate medications for acute pain management, especially after surgery. The nurse should not discriminate or stigmatize the client based on their history of opioid abuse, but rather provide compassionate and evidence-based care. The nurse should also use a multimodal approach to pain management, which involves using non-opioid analgesics, adjuvant medications, and non-pharmacological interventions, such as ice, heat, massage, or relaxation techniques.

Choice C reason: This statement is false. This client should not wait until their pain is severe, 10/10 before taking a high dose opioid, as this can result in poor pain control, increased stress, and delayed recovery. The nurse should encourage the client to take the medication as prescribed, and to report their pain level regularly. The nurse should also educate the client about the benefits of preventive analgesia, which involves taking the medication before the pain becomes severe, and maintaining a steady blood level of the drug.

Choice D reason: This statement is false. The client's self-report of pain may not be disregarded if they have a history of opioid abuse, as pain is a subjective and personal experience, and the client is the best judge of their own pain. The nurse should not assume that the client is exaggerating, lying, or drug-seeking, but rather respect and validate the client's pain report. The nurse should also use objective indicators of pain, such as vital signs, facial expressions, body movements, and behavioral changes, to support the client's pain assessment.