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

Answer and Explanation

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.

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Correct Answer is ["A","E","F"]

Explanation

Choice A reason: This statement is true. Distended neck veins are a sign of fluid volume overload, as they indicate increased central venous pressure and right-sided heart failure.

Choice B reason: This statement is false. Hypotension is a sign of fluid volume deficit, not fluid volume overload. Hypotension occurs when the blood pressure is too low to perfuse the vital organs.

Choice C reason: This statement is false. Increased serum osmolality is a sign of fluid volume deficit, not fluid volume overload. Increased serum osmolality occurs when the blood concentration of solutes, such as sodium and glucose, is too high due to fluid loss.

Choice D reason: This statement is false. Dry oral mucosa is a sign of fluid volume deficit, not fluid volume overload. Dry oral mucosa occurs when the oral cavity is dehydrated due to fluid loss.

Choice E reason: This statement is true. Decreased urine specific gravity is a sign of fluid volume overload, as it indicates diluted urine and impaired kidney function.

Choice F reason: This statement is true. Weight gain is a sign of fluid volume overload, as it indicates fluid retention and edema.

Choice G reason: This statement is false. Sunken anterior fontanelle is a sign of fluid volume deficit, not fluid volume overload. Sunken anterior fontanelle occurs when the soft spot on the baby's head is depressed due to fluid loss.

A. Ask the patient about home insulin doses B. Administer IV potassium supplements C. Place the patient on a cardiac monitor D. Start an insulin infusion at 0.1 units/kg/h

Correct Answer is B

Explanation

Choice A reason: This statement is false. Asking the patient about home insulin doses is not the action that the nurse should take first. Insulin is a hormone that lowers the blood glucose level and can also lower the blood potassium level by driving potassium into the cells. However, this is not the primary cause of hypokalemia, or low blood potassium level, which can be due to other factors such as diuretics, vomiting, diarrhea, or alkalosis.

Choice B reason: This statement is true. Administering IV potassium supplements is the action that the nurse should take first. Potassium is an electrolyte that is essential for the normal function of the heart, muscles, and nerves. Hypokalemia can cause cardiac arrhythmias, muscle weakness, and paralysis. IV potassium supplements can restore the blood potassium level and prevent life-threatening complications.

Choice C reason: This statement is false. Placing the patient on a cardiac monitor is not the action that the nurse should take first. A cardiac monitor is a device that records the electrical activity of the heart and can detect any abnormal rhythms or conduction problems. It is a useful tool for monitoring the patient's cardiac status, but it does not treat the underlying cause of hypokalemia.

Choice D reason: This statement is false. Starting an insulin infusion at 0.1 units/kg/h is not the action that the nurse should take first. Insulin infusion is a method of delivering insulin continuously through a pump or a catheter. It is used for patients with diabetes who need tight glucose control. It can also lower the blood potassium level by driving potassium into the cells. However, this is not t

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The nurse prioritizes which infant to administer pain medication to first? All have PRN (as needed) orders for pain medication.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client is admitted to the medical unit with fluid volume overload due to heart failure. Clinical manifestations of this problem are [Select all that apply]:

Correct Answer is ["A","E","F"]

Explanation

A client has a serum potassium level of 2.9 mEq/L. Which action prescribed by the health care provider should the nurse take first?

Correct Answer is B

Explanation

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