The nurse prioritizes which infant to administer pain medication to first? All have PRN (as needed) orders for pain medication.
A 12-month-old who is 2-days post-op cleft palate repair whose vital signs are within normal limits
A 6-month-old who is crying and becomes calm when held by a parent
An 8-month-old with legs drawn to chest and a temperature of 39.5 degrees C
A 4-month-old that has just returned from the recovery room
The Correct Answer is C
Choice A reason: This statement is false. A 12-month-old who is 2-days post-op cleft palate repair whose vital signs are within normal limits is not the priority for pain medication. This infant may have some pain from the surgery, but it is likely to be mild and manageable with non-pharmacological interventions, such as distraction, comfort, or oral care.
Choice B reason: This statement is false. A 6-month-old who is crying and becomes calm when held by a parent is not the priority for pain medication. This infant may have some pain from an unknown cause, but it is likely to be transient and responsive to non-pharmacological interventions, such as soothing, rocking, or cuddling.
Choice C reason: This statement is true. An 8-month-old with legs drawn to chest and a temperature of 39.5 degrees C is the priority for pain medication. This infant may have severe pain from an infection, such as appendicitis, meningitis, or urinary tract infection. This infant may also have signs of inflammation, such as fever, leukocytosis, or elevated C-reactive protein. This infant needs immediate pain relief and antibiotic therapy.
Choice D reason: This statement is false. A 4-month-old that has just returned from the recovery room is not the priority for pain medication. This infant may have some pain from the surgery, but it is likely to be moderate and controlled with pharmacological interventions, such as opioids, NSAIDs, or local anesthetics.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: A serum potassium level of 5.6 mEq/L is not a common side effect of furosemide, but of hyperkalemia. Hyperkalemia is a condition where the blood potassium level is too high. It can cause muscle weakness, irregular heartbeat, and cardiac arrest. Furosemide is a loop diuretic that increases the urinary excretion of water, sodium, chloride, and potassium. It can cause hypokalemia, which is a low blood potassium level, not hyperkalemia.
Choice B reason: A serum sodium level of 142 mEq/L is not a common side effect of furosemide, but of normal sodium level. The normal range of serum sodium level is 135 to 145 mEq/L. Sodium is an electrolyte that helps regulate the fluid balance, nerve impulses, and muscle contractions in the body. Furosemide can cause hyponatremia, which is a low blood sodium level, but not a normal sodium level.
Choice C reason: A serum sodium level of 138 mEq/L is also not a common side effect of furosemide, but of normal sodium level. As explained in choice B, the normal range of serum sodium level is 135 to 145 mEq/L. Furosemide can cause hyponatremia, which is a low blood sodium level, but not a normal sodium level.
Choice D reason: A serum potassium level of 2.8 mEq/L is a common side effect of furosemide, and of hypokalemia. Hypokalemia is a condition where the blood potassium level is too low. It can cause muscle cramps, fatigue, weakness, arrhythmias, and paralysis. Furosemide is a loop diuretic that increases the urinary excretion of water, sodium, chloride, and potassium. It can cause hypokalemia, which is a low blood potassium level. The nurse should monitor the client's serum potassium level and signs of hypokalemia, and advise the client to eat potassium-rich foods, such as bananas, oranges, and potatoes. The nurse should also report the lab value to the prescriber, who may adjust the dose of furosemide or prescribe a potassium supplement.
Correct Answer is C
Explanation
Choice A reason: 363 is not the correct answer. This is the daily maintenance fluid requirement for an infant who weighs 3.5 kg, not 16 kg. The formula for calculating the daily maintenance fluid requirement for infants who weigh between 3.5 and 10 kg is 100 mL/kg¹.
Choice B reason: 727 is not the correct answer. This is the daily maintenance fluid requirement for an infant who weighs 10 kg, not 16 kg. The formula for calculating the daily maintenance fluid requirement for infants who weigh between 10 and 20 kg is 1000 mL plus 50 mL for every kg over 10¹.
Choice C reason: 1300 is the correct answer. This is the daily maintenance fluid requirement for an infant who weighs 16 kg. The formula for calculating the daily maintenance fluid requirement for infants who weigh between 10 and 20 kg is 1000 mL plus 50 mL for every kg over 10¹. Therefore, for an infant who weighs 16 kg, the daily maintenance fluid requirement is 1000 mL plus 50 mL times 6, which equals 1300 mL.
Choice D reason: 1600 is not the correct answer. This is the daily maintenance fluid requirement for an infant who weighs 20 kg, not 16 kg. The formula for calculating the daily maintenance fluid requirement for infants who weigh between 10 and 20 kg is 1000 mL plus 50 mL for every kg over 10¹. For infants who weigh more than 20 kg, the formula is 1500 mL plus 20 mL for every kg over 20¹.
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