A 38-year-old man has come into the urgent care center with severe hip pain after falling from a ladder at work. He says he has taken several pain pills over the past few hours but cannot remember how many he has taken. He hands the nurse an empty bottle of acetaminophen (Tylenol). The nurse is aware that the most serious toxic effect of acute acetaminophen overdose is which condition?

Choice A reason: Performing an in/out catheterization is not a suitable method to measure urine output for a 10-month old client with dehydration. An in/out catheterization is a procedure where a catheter is inserted into the bladder through the urethra, and the urine is drained and measured. This method is invasive, painful, and carries the risk of infection and trauma. It is usually reserved for clients who have urinary retention or obstruction, or who need a sterile urine sample.

Choice B reason: Inserting a Foley catheter is also not an appropriate method to measure urine output for a 10-month old client with dehydration. A Foley catheter is a type of catheter that stays in the bladder and drains the urine into a collection bag. This method is also invasive, painful, and carries the risk of infection and trauma. It is usually used for clients who have urinary incontinence, surgery, or long-term bed rest.

Choice C reason: Collecting the client's urine in a cup is not a feasible method to measure urine output for a 10-month old client with dehydration. A cup is not a reliable or accurate device to collect and measure urine, especially for a young child who may not be toilet trained or cooperative. It is also difficult to ensure that all the urine is collected in the cup, and that the cup is not contaminated by other fluids or substances.

Choice D reason: Counting the number of wet diapers is the best method to measure urine output for a 10-month old client with dehydration. This method is non-invasive, simple, and practical. It can provide an estimate of the urine volume and frequency, and indicate the hydration status of the child. The nurse should weigh the diapers before and after use, and record the difference in grams. One gram of weight equals one milliliter of urine. The nurse should also observe the color, odor, and concentration of the urine. The normal urine output for a child is 1 to 2 mL/kg/hour.

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.