The nurse is assessing a 7-year-old post-surgery. Despite denying pain, the nurse observes the patient's fists are clenched and forehead is wrinkled. How will the nurse intervene?

Call the healthcare provider.

Wait for the patient to report pain.

Administer intravenous morphine.

Instruct the parent to play relaxing music.

Answer and Explanation

The Correct Answer is C

Choice A reason: Calling the healthcare provider is a valid action if the nurse encounters an unexpected issue or an emergency. However, in this situation, the nurse's immediate observation of physical signs indicating pain suggests that the patient might be experiencing discomfort. The nurse has enough clinical judgment to address the pain directly rather than waiting for a healthcare provider's intervention, which could delay relief.

Choice B reason: Waiting for the patient to report pain is not an ideal choice here because children, especially younger ones, may not always verbalize their pain even when they are in discomfort. The nurse's role involves assessing both verbal and non-verbal cues to provide timely and appropriate care. Physical signs such as clenched fists and a wrinkled forehead strongly indicate pain, necessitating prompt action rather than waiting.

Choice C reason: Administering intravenous morphine is the appropriate intervention given the clear physical signs of pain observed by the nurse. Morphine is a powerful opioid analgesic used to manage moderate to severe pain. In a post-surgical context, controlling pain effectively is crucial for the patient's recovery. Therefore, this action aligns with the need for timely pain management to ensure the child's comfort and facilitate healing.

Choice D reason: Instructing the parent to play relaxing music can be a helpful non-pharmacological intervention to provide a calming environment for the child. However, this action alone is unlikely to address the acute pain suggested by the patient's physical signs. While it can be part of a comprehensive pain management plan, the primary approach should be administering medication to relieve the immediate pain.

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Correct Answer is B

Explanation

Choice A reason: A newborn at 41 weeks and 5 days gestation is past full term and, while being older in gestational age, does not typically present increased risk for feeding difficulties as compared to preterm infants. At 6 hours old, this infant would still be adapting, but no additional risk is posed by the gestational age.

Choice B reason: An infant born at 36 weeks and 6 days gestation is considered late preterm. Late preterm infants often have immature suck and swallow reflexes and may experience difficulties with feeding, coordinating breathing with feeding, and maintaining body temperature. These issues place them at a higher risk for feeding difficulties compared to full-term infants.

Choice C reason: A newborn at 37 weeks and 3 days gestation is considered early term and generally faces fewer risks compared to preterm infants. At 34 hours old, feeding patterns are still being established, but there are no significant additional risks related to their gestational age.

Choice D reason: An infant born at 38 weeks gestation is considered full term. At 27 hours old, the baby would still be in the early stages of adapting to feeding, but being full term generally implies a lower risk for feeding difficulties compared to preterm infants.

A. Salmeterol B. Prednisone C. Ibuterol D. Par

Correct Answer is A

Explanation

Choice A reason: Salmeterol, a long-acting beta-agonist (LABA), is generally not recommended for use during pregnancy due to potential risks to the fetes. It is typically avoided unless absolutely necessary and other safer options are not effective.

Choice B reason: Prednisone is a corticosteroid that can be used during pregnancy when necessary. It is often prescribed for managing severe asthma symptoms, but it should be used under close medical supervision to minimize potential risks.

Choice C reason: Ibuterol is a short-acting beta-agonist (SABA) and is generally considered safe for use during pregnancy. It is commonly used as a rescue inhaler to relieve acute asthma symptoms.

Choice D reason: The text for option D is incomplete and does not provide sufficient information to determine its relevance to the question.

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The nurse is assessing a 7-year-old post-surgery. Despite denying pain, the nurse observes the patient's fists are clenched and forehead is wrinkled. How will the nurse intervene?

Nursing Test Bank

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