The nurse is caring for a child who is receiving a narcotic for pain relief. Which of the following assessment should be a priority in monitoring the child (select all that apply)?
Respirations
Level of consciousness
Oxygen saturations.
Bowel Sounds
Correct Answer : A,B,C
A. Respirations: Monitoring respiratory rate and pattern is crucial when a child is receiving narcotics, as these medications can depress the respiratory system. Rapid or shallow breathing may indicate respiratory distress.
B. Level of consciousness: This is important to assess for any signs of sedation or altered mental status, which can be a side effect of narcotics.
C. Oxygen saturations: Monitoring oxygen saturations is essential, especially if there are concerns about respiratory depression. A decrease in oxygen saturations could indicate inadequate ventilation.
D. Bowel sounds: While bowel sounds are important to assess for gastrointestinal function, they are not the top priority when monitoring a child receiving narcotics. Respiratory and central nervous system status take precedence.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
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.
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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