The nurse is assessing the pain of a neonate who is admitted to the NICU with a heart defect. Which pain assessment scale would be the best tool to use with this patient?
A. CRIES scale
B. COMFORT scale
C. FLACC scale
...
The nurse is assessing the pain of a neonate who is admitted to the NICU with a heart defect. Which pain assessment scale would be the best tool to use with this patient?
A. CRIES scale
B. COMFORT scale
C. FLACC scale
D. FACES scale - Answer>>> A. The CRIES Pain Scale is a tool intended for use with neonates and infants from 0 to 6 months. The COMFORT Scale, used to assess pain and distress in critically ill pediatric patients, relies on six behavioral and two physiologic factors that determine the level of analgesia needed to adequately relieve pain in these children. The FLACC scale (F—Faces, L—Legs, A—Activity, C—Cry, C—Consolability) was designed for infants and children from age 2 months to 7 years who are unable to validate the presence or severity of pain. The FACES scale is used for children who can compare their pain to the faces depicted on the scale.
The nurse collects objective and subjective data when conducting patient assessments. Which patient conditions are examples of subjective data? Select all that apply.
A. A patient tells the nurse that she is feeling nauseous.
B. A patient's ankles are swollen.
C. A patient tells the nurse that she is nervous about her test results.
D. A patient complains of having a rash on her arm that is itchy.
E. A patient rates his pain as a 7 on a scale of 1 to 10.
F. A patient vomits after eating supper. - Answer>>> A, C, D, E
Amount of blood that is pumped through the heart each minute - Answer>>> 3.5-8 L/min
The nurse is surprised to detect an elevated temperature (102°F) in a patient scheduled for surgery. The patient has been afebrile and shows no other signs of being febrile. What is the first thing the nurse should do?
A. Inform the charge nurse.
B. Inform the surgeon.
C. Validate the finding.
D. Document the finding. - Answer>>> C. The nurse should first validate the finding if it is unusual, deviates from normal, and is unsupported by other data. Should the initial recording prove to be in error, it would have been premature to notify the charge nurse or the surgeon. The nurse should be sure that all data recorded are accurate, thus all data should be validated before documentation if there are any doubts about accuracy.
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