A nurse is caring for a six-year-old child who had surgery that morning.
The child is awake and lying very still in bed.
What should the nurse do?

Choice A rationale

Assessing pulses and blood pressure is crucial before administering an antiarrhythmic agent because these drugs can affect heart rate and blood pressure, requiring close monitoring to prevent adverse effects.

Choice B rationale

While assessing breath sounds is important in overall patient care, it is not the priority before administering antiarrhythmic agents as these drugs primarily affect the cardiovascular system.

Choice C rationale

Assessing mental status is important in patient care, but it is not the priority before administering an antiarrhythmic agent, as these medications primarily influence cardiovascular parameters.

Choice D rationale

Assessing urine output is vital for monitoring kidney function and fluid balance, but it is not the priority before administering an antiarrhythmic agent, which mainly affects heart rhythm and blood pressure.

Choice A rationale

Using an “ouch” scale, such as the Wong-Baker FACES Pain Rating Scale, is appropriate for young children. It allows them to express their pain intensity in a way that is understandable and relatable to their age group.

Choice B rationale

Encouraging a six-year-old to request pain medication may not be effective, as they might not understand when they need it or might be reluctant to ask.

Choice C rationale

Waiting to administer pain medication until the child begins to cry can delay pain relief, leading to unnecessary discomfort and anxiety.

Choice D rationale

Asking a young child to rate their pain on a scale of 1 to 10 might be confusing and less effective than using a more child-friendly method like the “ouch” scale.