A six-year-old complains of pain at the surgical site, one hour after the nurse gave IV morphine, which is ordered every four hours prn pain. What is the nurse's best next step?

Ask the patient to wait a little longer for the medicine to work.

Review whether the morphine dose is therapeutic for his weight.

Call the physician immediately.

Encourage the child to use television as a form of distraction.

Answer and Explanation

The Correct Answer is C

A. Ask the patient to wait a little longer for the medicine to work.
This option may not be appropriate, especially if the child is experiencing significant pain. It's essential to address the child's pain promptly rather than asking them to wait, as adequate pain management is crucial for the child's well-being.
B. Review whether the morphine dose is therapeutic for his weight.
While reviewing the dose for the child's weight is important, it may not be the immediate next step in this situation. If the child is experiencing pain that persists after one hour, the priority is to address the immediate pain concern. The nurse can later review the medication orders and dosages in collaboration with the healthcare provider.
C. Call the physician immediately.
This is the most appropriate next step in this scenario. If the child is experiencing pain despite having received morphine one hour ago, contacting the physician is important to discuss the current situation, assess the need for additional pain management, and potentially make adjustments to the treatment plan.
D. Encourage the child to use television as a form of distraction.
Distraction can be a helpful complementary measure for managing pain, but it may not be sufficient in this case if the pain persists. The primary focus should be on addressing the pain through appropriate medical interventions, and calling the physician is a more urgent step.

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Correct Answer is C

Explanation

A. Begin with taking all the vital signs.

This is not the preferred approach for assessing a 10-month-old infant. Vital signs may be intimidating and intrusive, and starting with less invasive methods is generally recommended.

B. Use the Faces scale to rate their pain.

The Faces scale is typically used for older children who can express themselves verbally. It may not be suitable for a 10-month-old infant.

C. Start with less intrusive methods.

This is the correct choice. Beginning with less intrusive methods, such as observation and gentle interactions, helps build trust and ensures the infant is comfortable during the assessment.

D. Be systematic and go in a head-to-toe order.

While being systematic is important, starting with less intrusive methods and adapting the approach based on the infant's response is generally more appropriate than a strict head-to-toe order.

A. 21pounds B. 14 pounds C. 25 pounds D. 10 pounds

Correct Answer is A

Explanation

A. 21 pounds: This is the correct answer. The general guideline is that infants tend to triple their birth weight by the age of 12 months. If the infant weighed 7 pounds at birth, tripling that weight would be 21 pounds.

B. 14 pounds: This weight would not be consistent with the expected weight gain of a healthy infant by 12 months. It's too low based on the tripling guideline.

C. 25 pounds: This weight would be higher than expected based on the tripling guideline. It's not a typical weight for a healthy 12-month-old who had a birth weight of 7 pounds.

D. 10 pounds: This weight would be lower than the expected weight gain. A 12-month-old who started at 7 pounds should have gained more weight by this age.

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A six-year-old complains of pain at the surgical site, one hour after the nurse gave IV morphine, which is ordered every four hours prn pain. What is the nurse's best next step?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is planning to assess a 10 month-old infant and bases the assessment on which rationale?

Correct Answer is C

Explanation

The nurse is assessing a 12-month-old healthy infant who weighed 7 pounds at birth. The nurse should expect the infant to now weigh approximately:

Correct Answer is A

Explanation

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