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 C
Explanation
Choice A reason: This statement is false. Nephropathy is a term that refers to any disease or damage of the kidneys. Acetaminophen overdose can cause nephropathy, but it is not the most serious toxic effect. Nephropathy can manifest as reduced urine output, increased blood urea nitrogen and creatinine levels, and electrolyte imbalance.
Choice B reason: This statement is false. Tachycardia is a term that refers to a fast heart rate, usually more than 100 beats per minute. Acetaminophen overdose can cause tachycardia, but it is not the most serious toxic effect. Tachycardia can be a sign of dehydration, fever, pain, or anxiety.
Choice C reason: This statement is true. Liver dysfunction is the most serious toxic effect of acute acetaminophen overdose. Acetaminophen is metabolized by the liver and can produce a toxic byproduct that damages the liver cells. Liver dysfunction can manifest as jaundice, abdominal pain, nausea, vomiting, and elevated liver enzymes.
Choice D reason: This statement is false. Central nervous system depression is a term that refers to a reduced level of consciousness, alertness, and responsiveness. Acetaminophen overdose can cause central nervous system depression, but it is not the most serious toxic effect. Central nervous system depression can be a sign of hypoxia, hypoglycemia, or drug intoxication.
Correct Answer is D
Explanation
Choice A reason: This statement is false. A serum potassium level of 5.6 mEq/L is not a common side effect of furosemide. This value indicates hyperkalemia, or high blood potassium level, which can cause cardiac arrhythmias and muscle weakness. Furosemide is a loop diuretic that causes potassium loss, not retention.
Choice B reason: This statement is false. A serum sodium level of 142 mEq/L is not a common side effect of furosemide. This value is within the normal range of 135-145 mEq/L and does not indicate any problem with sodium balance. Furosemide is a loop diuretic that causes sodium loss, but it is usually compensated by the renin-angiotensin-aldosterone system.
Choice C reason: This statement is false. A serum sodium level of 138 mEq/L is not a common side effect of furosemide. This value is within the normal range of 135-145 mEq/L and does not indicate any problem with sodium balance. Furosemide is a loop diuretic that causes sodium loss, but it is usually compensated by the renin-angiotensin-aldosterone system.
Choice D reason: This statement is true. A serum potassium level of 2.8 mEq/L is a common side effect of furosemide. This value indicates hypokalemia, or low blood potassium level, which can cause cardiac arrhythmias, muscle weakness, and metabolic alkalosis. Furosemide is a loop diuretic that inhibits the reabsorption of sodium and potassium in the ascending loop of Henle, leading to potassium loss in the urine.
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