Score T.M. on the FLACC pain scale. Why is the FLACC scale an appropriate tool?
What will be an ideal response?
T.M. would score a 3 of 10; 1 for restlessness, 1 for occasional frowning, 1 for reassurance by parents.
FLACC is an observational scale appropriate for use in children 2 to 10 years of age and patients who are
nonverbal and unable to communicate a pain score. The scale evaluates facial expression, leg movement,
activity, cry, and consolability. Each criterion is scored 0 to 2 for a total FLACC score of 0 to 10.
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The nurse knows that which of the following skills does not require the use of sterile technique?
a. NG tube insertion b. Foley catheterization c. Tracheostomy care d. PICC line insertion
The nurse is preparing a patient for an ECG. Which of the following should be done prior to electrode placement?
A) Cleaning the skin with povidone-iodine solution prior to applying the electrodes B) Ensuring that the area for electrode placement is dry C) Applying tincture of benzoin to the electrode sites and waiting for it to become "tacky" D) Abrading the skin by rubbing the electrode sites briskly with a rough surface such as a clean, dry gauze or washcloth
The nurse should expect medical intervention for subinvolution to include:
a. oral fluids to 3000 mL/day. b. intravenous fluid and blood replacement. c. oxytocin intravenous infusion for 8 hours. d. oral methylergonovine maleate (Methergine) for 48 hours.
When an infant is receiving phototherapy with standard high-intensity lights, the nurse should explain to the parents that:
a. The infant's eyes will be covered because the bright light would prevent sleep. b. The infant can be removed from the light for feeding and short visits. c. Lotion can be applied to moisturize the skin before treatments. d. The infant will remain under the light at all times.