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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. The child's current vital signs are consistent with vital signs over the past 4 hours.
Vital signs alone may not be sufficient to assess pain in a child. Children may experience pain without significant changes in vital signs. Behavioral cues and self-reporting are important indicators of pain in pediatric patients.
B. The child becomes quiet when held and cuddled.
While seeking comfort through cuddling may be a sign of distress or discomfort, it is not specific enough to determine the need for pain medication. Additional assessment is required to understand the underlying cause of the child's change in behavior.
C. The child has a temperature of 38.5°C.
Fever alone does not necessarily indicate the need for pain medication. It may suggest an infection or illness, but the specific assessment of pain requires consideration of the child's behavior, verbal expressions, and any other cues related to pain.
D. The child is lying stiffly in bed, not moving, and refusing to get up.
In this scenario, the child's behavior of lying stiffly in bed, not moving, and refusing to get up is indicative of potential pain. Children may express pain in various ways, and behavioral cues such as changes in activity, refusal to move, or guarding certain body parts can suggest discomfort. It is important for the nurse to assess and address the child's pain promptly.
Correct Answer is C
Explanation
A. Serum calcium:
- Serum calcium levels are not typically used to diagnose cystic fibrosis. Calcium levels are more related to bone health, neuromuscular function, and various metabolic processes. While electrolyte imbalances can occur in CF, serum calcium alone is not specific for its diagnosis.
B. Urine creatinine:
- Urine creatinine is not a diagnostic test for cystic fibrosis. Creatinine is a waste product produced by muscles and excreted by the kidneys. Monitoring creatinine levels is more related to assessing kidney function and is not specific to CF diagnosis.
C. Sweat chloride test:
- The sweat chloride test is considered the gold standard for diagnosing cystic fibrosis. Individuals with CF have higher than normal levels of chloride in their sweat. This test measures the amount of chloride in the sweat, and a high level is indicative of CF. It is a noninvasive and reliable diagnostic test for CF.
D. Bronchoscopy:
- Bronchoscopy is not used as a primary diagnostic test for cystic fibrosis. While it may be performed for other reasons, such as assessing airway abnormalities or obtaining samples for culture, it is not the primary method for diagnosing CF.
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