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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: A serum potassium level of 5.6 mEq/L is not a common side effect of furosemide, but of hyperkalemia. Hyperkalemia is a condition where the blood potassium level is too high. It can cause muscle weakness, irregular heartbeat, and cardiac arrest. Furosemide is a loop diuretic that increases the urinary excretion of water, sodium, chloride, and potassium. It can cause hypokalemia, which is a low blood potassium level, not hyperkalemia.
Choice B reason: A serum sodium level of 142 mEq/L is not a common side effect of furosemide, but of normal sodium level. The normal range of serum sodium level is 135 to 145 mEq/L. Sodium is an electrolyte that helps regulate the fluid balance, nerve impulses, and muscle contractions in the body. Furosemide can cause hyponatremia, which is a low blood sodium level, but not a normal sodium level.
Choice C reason: A serum sodium level of 138 mEq/L is also not a common side effect of furosemide, but of normal sodium level. As explained in choice B, the normal range of serum sodium level is 135 to 145 mEq/L. Furosemide can cause hyponatremia, which is a low blood sodium level, but not a normal sodium level.
Choice D reason: A serum potassium level of 2.8 mEq/L is a common side effect of furosemide, and of hypokalemia. Hypokalemia is a condition where the blood potassium level is too low. It can cause muscle cramps, fatigue, weakness, arrhythmias, and paralysis. Furosemide is a loop diuretic that increases the urinary excretion of water, sodium, chloride, and potassium. It can cause hypokalemia, which is a low blood potassium level. The nurse should monitor the client's serum potassium level and signs of hypokalemia, and advise the client to eat potassium-rich foods, such as bananas, oranges, and potatoes. The nurse should also report the lab value to the prescriber, who may adjust the dose of furosemide or prescribe a potassium supplement.
Correct Answer is A
Explanation
Choice A reason: This statement is true. This client may have a high tolerance to opioids and require a higher dose for pain control, as tolerance is a condition where the body becomes less responsive to the effects of a drug over time, and needs more of the drug to achieve the same effect. Tolerance can develop from chronic or repeated use of opioids, and can vary from person to person. The nurse should assess the client's pain level, history of opioid use, and response to the medication, and adjust the dose accordingly.
Choice B reason: This statement is false. Clients with a history of opioid abuse should not be denied an opioid analgesic, as opioids are effective and appropriate medications for acute pain management, especially after surgery. The nurse should not discriminate or stigmatize the client based on their history of opioid abuse, but rather provide compassionate and evidence-based care. The nurse should also use a multimodal approach to pain management, which involves using non-opioid analgesics, adjuvant medications, and non-pharmacological interventions, such as ice, heat, massage, or relaxation techniques.
Choice C reason: This statement is false. This client should not wait until their pain is severe, 10/10 before taking a high dose opioid, as this can result in poor pain control, increased stress, and delayed recovery. The nurse should encourage the client to take the medication as prescribed, and to report their pain level regularly. The nurse should also educate the client about the benefits of preventive analgesia, which involves taking the medication before the pain becomes severe, and maintaining a steady blood level of the drug.
Choice D reason: This statement is false. The client's self-report of pain may not be disregarded if they have a history of opioid abuse, as pain is a subjective and personal experience, and the client is the best judge of their own pain. The nurse should not assume that the client is exaggerating, lying, or drug-seeking, but rather respect and validate the client's pain report. The nurse should also use objective indicators of pain, such as vital signs, facial expressions, body movements, and behavioral changes, to support the client's pain assessment.
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