A nurse is assessing a 2-year-old child following a surgical procedure. Which of the following pain tools should the nurse use?

Face, legs, activity, cry, consolability (FLACC) scale

Oucher scale

FACES scale

Visual analog scale (VAS)

Answer and Explanation

The Correct Answer is A

A. Face, legs, activity, cry, consolability (FLACC) scale: The FLACC scale is appropriate for children aged 2 months to 7 years and assesses pain based on non-verbal cues such as facial expression, leg movement, activity, crying, and consolability.
B. Oucher scale and C. FACES scale are more appropriate for children aged 3 years and older who can self-report their pain.
D. Visual analog scale (VAS) is suitable for older children (typically 8 years and older) who can understand the concept of a continuum of pain.

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Free Nursing Study Resources

Correct Answer is A

Explanation

A. Monitor temporal artery temperature: Regularly checking the temporal artery temperature can help identify a fever early, allowing for prompt intervention if necessary.
B. Restrain the infant's wrists: Soft elbow restraints (not wrist restraints) are commonly used for infants post-cleft lip repair to prevent them from touching or rubbing the surgical site, which could disrupt the sutures and delay healing.
C. Place the infant in a prone position: After cleft lip surgery, infants should be positioned on their back to avoid pressure on the sutures and reduce the risk of injury.
D. Gently clean the suture line with povidone-iodine solution: It is typically recommended to clean the suture line with a sterile saline solution rather than povidone-iodine, which may irritate the site. Additionally, care should be taken to avoid disturbing the area too much.

A. Insert the tip of the thermometer 5 cm (2 in) into the rectum. B. Place the child in prone position. C. Stabilize the thermometer at the distal end. D. Direct the tip of the thermometer toward the spine during insertion. E. None F. None

Correct Answer is B

No explanation

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A nurse is assessing a 2-year-old child following a surgical procedure. Which of the following pain tools should the nurse use?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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