A nursing student sees the nurse dip a pacifier in a sugar-water solution for an infant before administering an intramuscular injection. The nursing student asks why the nurse provided this sugar-water pacifier. The nurse’s appropriate response is: This will:
Help the vaccination be more effective
Prevent hypoglycemia from the stress of the injection
Provide additional calories to prevent malnourishment
Soothe and distract the infant from pain
The Correct Answer is D
Choice A reason: This statement is false. A sugar-water pacifier does not help the vaccination be more effective. Vaccinations are effective because they stimulate the immune system to produce antibodies against a specific disease.
Choice B reason: This statement is false. A sugar-water pacifier does not prevent hypoglycemia from the stress of the injection. Hypoglycemia is a condition where the blood sugar level is too low, which can cause symptoms such as sweating, trembling, confusion, or seizures. A sugar-water pacifier does not provide enough glucose to prevent hypoglycemia.
Choice C reason: This statement is false. A sugar-water pacifier does not provide additional calories to prevent malnourishment. Malnourishment is a condition where the body does not get enough nutrients, such as protein, vitamins, and minerals, to function properly. A sugar-water pacifier does not provide enough nutrients to prevent malnourishment.
Choice D reason: This statement is true. A sugar-water pacifier soothes and distracts the infant from pain. Sugar-water has a sweet taste that activates the endorphin system, which reduces pain perception. A pacifier also provides oral stimulation and comfort, which distracts the infant from the pain of the injection.
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Related Questions
Correct Answer is B
Explanation
Choice A reason: This statement is false. Asking the patient about home insulin doses is not the action that the nurse should take first. Insulin is a hormone that lowers the blood glucose level and can also lower the blood potassium level by driving potassium into the cells. However, this is not the primary cause of hypokalemia, or low blood potassium level, which can be due to other factors such as diuretics, vomiting, diarrhea, or alkalosis.
Choice B reason: This statement is true. Administering IV potassium supplements is the action that the nurse should take first. Potassium is an electrolyte that is essential for the normal function of the heart, muscles, and nerves. Hypokalemia can cause cardiac arrhythmias, muscle weakness, and paralysis. IV potassium supplements can restore the blood potassium level and prevent life-threatening complications.
Choice C reason: This statement is false. Placing the patient on a cardiac monitor is not the action that the nurse should take first. A cardiac monitor is a device that records the electrical activity of the heart and can detect any abnormal rhythms or conduction problems. It is a useful tool for monitoring the patient's cardiac status, but it does not treat the underlying cause of hypokalemia.
Choice D reason: This statement is false. Starting an insulin infusion at 0.1 units/kg/h is not the action that the nurse should take first. Insulin infusion is a method of delivering insulin continuously through a pump or a catheter. It is used for patients with diabetes who need tight glucose control. It can also lower the blood potassium level by driving potassium into the cells. However, this is not t
Correct Answer is ["A","B","D","E","F"]
Explanation
Choice A reason: This statement is true. Assessing mental status and level of consciousness is an important consideration for this treatment, as morphine can cause sedation, confusion, and respiratory depression. The nurse should monitor the client's orientation, alertness, and responsiveness, and use a sedation scale to evaluate the degree of sedation.
Choice B reason: This statement is true. Assessing urine output frequently is an important consideration for this treatment, as morphine can cause urinary retention, which can lead to bladder distension, infection, or kidney damage. The nurse should measure the client's urine output and check for signs of bladder fullness or discomfort.
Choice C reason: This statement is false. Monitoring potassium levels is not an important consideration for this treatment, as morphine does not affect the blood potassium level. Potassium is an electrolyte that is essential for the normal function of the heart, muscles, and nerves. Potassium imbalance can be caused by other factors, such as diuretics, vomiting, diarrhea, or acid-base disorders.
Choice D reason: This statement is true. Teaching the family that only the client can press the button for pain medication is an important consideration for this treatment, as PCA Pump allows the client to self-administer a preset dose of morphine within a specified time interval. The family should not press the button for the client, as this can result in overmedication, overdose, or addiction.
Choice E reason: This statement is true. Ensuring there is an order for Naloxone in case of overdose is an important consideration for this treatment, as Naloxone is an antidote that can reverse the effects of morphine in the event of an overdose. Naloxone can restore the client's breathing, blood pressure, and consciousness, and prevent death.
Choice F reason: This statement is true. Assessing CO2 levels is an important consideration for this treatment, as morphine can cause respiratory depression, which can lead to hypercapnia, or high blood carbon dioxide level. Hypercapnia can cause headache, drowsiness, confusion, and coma. The nurse should monitor the client's respiratory rate, depth, and rhythm, and use a capnograph or a blood gas analysis to measure the CO2 level.
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