Nokea
The physician orders an I.V. opioid analgesic. Which finding by the nurse would best indicate that the I.V. opioid analgesic is effective?
- A. The respiratory rate is within normal limits.
- B. The child's pain level remains stable.
- C. The child is watching television.
- D. The urine output is 30 mL/hour.
Correct Answer: C
Rationale: A child watching television suggests they are comfortable and distracted from pain, indicating effective pain relief from the opioid. Stable pain levels or normal respiratory rate do not directly confirm pain control.
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Which nursing instruction is correct for the parents of a child who has a vitamin D deficiency?
- A. Give the child cod liver oil daily.
- B. Give the child orange juice daily.
- C. Apply sunblock to the child before sun exposure.
- D. Keep the child indoors during daylight hours.
Correct Answer: A
Rationale: Cod liver oil is a rich source of vitamin D, essential for correcting vitamin D deficiency and supporting bone health.
The nurse should plan to keep which equipment or supplies in the burned child's room in case an emergency arises?
- A. An extra supply of sterile dressing
- B. An endotracheal tube and oxygen supply
- C. Equipment to administer pain medication
- D. Additional bags of I.V. fluid
Correct Answer: B
Rationale: Burn patients are at risk for airway compromise due to inhalation injury or edema. Keeping an endotracheal tube and oxygen supply available is critical for emergency airway management.
Which assessment finding may indicate a serious neurovascular problem that should be reported immediately to the charge nurse or physician?
- A. The toes of the left foot are warmer than the toes of the right foot.
- B. The toes of both feet are cool to the touch.
- C. The child is unable to wiggle the toes of the right foot.
- D. The capillary refill in the toes of the right foot is 2 seconds.
Correct Answer: C
Rationale: Inability to wiggle toes suggests neurovascular compromise, such as nerve or vascular injury, requiring immediate reporting to prevent permanent damage.
Which information about methamphetamine use is most accurate and important for the parents to know?
- A. Methamphetamines are tried by most adolescents and cause no harm.
- B. Methamphetamines are known to lead to addiction.
- C. Methamphetamines are a central nervous system depressant.
- D. Methamphetamines are harmful only if taken intravenously.
Correct Answer: B
Rationale: Methamphetamines are highly addictive stimulants, and informing parents about the risk of addiction is critical to understanding the severity of the adolescent's behavior.
The nurse caring for a 32-weeks’ gestation infant is about to perform a heel stick to obtain blood for a prescribed test. Which intervention should the nurse utilize to minimize the amount of pain the neonate will experience?
- A. Apply an ice pack
- B. Apply a heel warmer
- C. Give morphine sulfate
- D. Give sucrose or Sweet-Ease
Correct Answer: D
Rationale: Sucrose activates the endogenous opioid system providing analgesia for 3–5 minutes when given 2 minutes prior to a heel stick. Ice risks skin damage heel warmers aid blood flow and morphine is inappropriate.