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A nurse is assessing a 3-month-old patient who underwent a pyloromyotomy the previous day.
Which of the following findings would indicate a need for pain medication? Select all that apply.

Increased pulse rate.

Skin showing peripheral pallor.

Clenched fists.

Increased respiratory rate.

Restlessness.

Elevated temperature.

Answer and Explanation

Correct Answer : A,C,D,E,F

Choice A rationale

An increased pulse rate can be a sign of pain in infants. The heart rate increases as the body’s way of coping with the stress of pain.

Choice B rationale

Skin showing peripheral pallor is not typically associated with pain. It can be a sign of other conditions, such as anemia or shock, but it’s not a reliable indicator of pain.

Choice C rationale

Clenched fists can be a sign of pain in infants. It’s a common non-verbal cue that infants use to express discomfort.

Choice D rationale

An increased respiratory rate can also be a sign of pain. Like an increased heart rate, it’s a physiological response to stress.

Choice E rationale

Restlessness can be a sign of discomfort or pain in infants. Infants may squirm, fidget, or have trouble settling down when they’re in pain.

Choice F rationale

An elevated temperature is not typically a direct sign of pain, but it can indicate an underlying condition that might be causing pain, such as an infection.

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Correct Answer is D

Explanation

Choice A rationale

Applying ice, then a warm compress to the IV site may help with pain or inflammation, but it does not address the potential problem with the IV site itself. If the client is experiencing pain and refuses a flush to assess the site, it could indicate that the IV site is compromised.

Choice B rationale

Checking the medical record for the date of IV insertion could provide useful information about how long the IV has been in place, but it does not directly address the client’s current complaint of pain at the IV site.

Choice C rationale

Redressing the IV site while checking for redness could help identify signs of infection or inflammation, but it does not address the client’s complaint of pain or their refusal to have the site flushed.

Choice D rationale

Discontinuing the current IV site and inserting a new one is the most appropriate action in this situation. If the client is experiencing pain at the IV site and refuses a flush to assess the site, it suggests that the current IV site may be compromised. Inserting a new IV ensures that the client can continue to receive their scheduled IV medication safely.

A. Limit activity for a day or two after returning home. B. Anticipate a stinging feeling during needle insertion. C. Prepare to sit forward with arms propped on a table. D. Expect a persistent cough after the procedure.

Correct Answer is D

Explanation

Choice A rationale

Limiting activity for a day or two after returning home is a correct understanding. After a thoracentesis, it’s recommended to limit activity for a day or two to allow the body to recover.

Choice B rationale

Anticipating a stinging feeling during needle insertion is a correct understanding. The patient will feel a stinging sensation when the local anesthetic is injected.

Choice C rationale

Preparing to sit forward with arms propped on a table is a correct understanding. This position helps to expand the space between the ribs, making it easier for the doctor to access the pleural space.

Choice D rationale

Expecting a persistent cough after the procedure indicates a need for additional education. While a mild cough immediately after the procedure is normal, a persistent cough could indicate a complication such as a pneumothorax.

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A nurse is assessing a 3-month-old patient who underwent a pyloromyotomy the previous day.Which of the following findings would indicate a need for pain medication? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

While preparing to administer a scheduled IV medication, a client complains of pain at the IV site and refuses a flush to assess the site.What should the nurse do next?

Correct Answer is D

Explanation

The nurse is preparing a client for an outpatient thoracentesis.Which statement made by the client indicates a need for additional education?

Correct Answer is D

Explanation

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A nurse is assessing a 3-month-old patient who underwent a pyloromyotomy the previous day.
Which of the following findings would indicate a need for pain medication? Select all that apply.