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. Bronchiolitis:
Bronchiolitis is typically characterized by inflammation of the bronchioles, causing symptoms such as wheezing and respiratory distress. However, the symptom of tasting salt on the skin is not directly associated with bronchiolitis.
B. Pharyngitis:
Pharyngitis, or inflammation of the throat, may cause symptoms like a sore throat, but it is not typically associated with a salty taste on the skin.
C. Asthma:
Asthma is a chronic condition characterized by airway inflammation and bronchoconstriction. While it can cause respiratory symptoms, it is not specifically associated with a salty taste on the skin.
D. Cystic Fibrosis:
Cystic Fibrosis is a genetic disorder that affects the respiratory, digestive, and reproductive systems. It often leads to salty-tasting skin due to increased salt content in sweat. The presence of a salty taste on the skin can be a significant indicator of cystic fibrosis.
Correct Answer is D
Explanation
A. Informing the child's parents about a tonsillectomy:
Tonsillectomy is not the immediate intervention for the symptoms described. This intervention is not necessary at this point.
B. Immediate IV placement:
While hydration may be necessary, immediate IV placement is not the primary intervention for a child with croup presenting with stridor and hoarseness.
C. A tracheostomy set at the bedside:
While croup can cause airway obstruction, preparing for a tracheostomy is not the initial intervention. Less invasive measures are typically attempted first.
D. Cool mist and respiratory treatment of racemic epinephrine:
This is the correct intervention. Croup, often caused by viral infections, can result in swelling of the upper airway, leading to the characteristic barky cough, stridor, and hoarseness. Administration of cool mist and racemic epinephrine can help reduce airway swelling and alleviate symptoms.
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