A nurse is monitoring an infant who is receiving opioids for pain.
Which of the following findings should indicate to the nurse that the medication is having a therapeutic effect?

Choice A rationale:

The preschool-age child with muffled voice and no spontaneous cough might be experiencing a medical emergency, possibly epiglottitis. This condition can rapidly progress and compromise the airway, necessitating immediate assessment and intervention.

Choice B rationale:

The school-age child with diabetes and a blood glucose of 200 mg/dL requires attention, but it is not an immediate concern unless the child is showing signs of diabetic ketoacidosis (DKA), such as altered mental status or deep, labored breathing, which are not mentioned in the question.

Choice C rationale:

The toddler with nephrotic syndrome and facial edema needs monitoring and intervention, but it doesn't indicate an immediate life-threatening condition compared to the child with potential airway compromise (muffled voice and no spontaneous cough)

Choice D rationale:

The adolescent with Crohn's disease and recent weight loss also needs attention, but it's not as urgent as the child with potential airway obstruction. Weight loss alone, while concerning, doesn't necessitate immediate assessment in this context.

Choice A rationale:

Check the toddler's ID band against the medical record. Verifying the toddler's identity through their ID band is a standard and reliable practice in healthcare settings. It ensures that the right medication is administered to the right patient, promoting patient safety and preventing medication errors. Checking the ID band against the medical record is a fundamental step in the medication administration process.

Choice B rationale:

Ask another nurse to confirm the toddler's identity. While collaboration and double-checking are important in healthcare settings, the primary responsibility lies with the nurse administering the medication. Relying solely on another nurse to confirm the toddler's identity could lead to errors. Nurses should follow established protocols, including checking the ID band, to maintain patient safety.

Choice C rationale:

Check the toddler's room number against their ID band. Verifying the room number is not a reliable method of confirming a patient's identity. Room assignments can change, and patients can be moved to different locations within the healthcare facility. Relying on room numbers can lead to confusion and errors in identifying patients.

Choice D rationale:

Ask the parent to confirm the toddler's identity. While involving parents in the care process is important, the primary responsibility for confirming a patient's identity lies with the healthcare provider. Parents can assist by providing information, but the final verification should be done through established healthcare protocols, such as checking the ID band against the medical record.