A nurse is caring for a 6-month-old infant who is postoperative following a myringotomy. Which of the following pain scales should the nurse use to determine the infant’s pain level?
Visual Analog Scale.
FLACC.
Oucher.
Faces.
The Correct Answer is B
Choice A rationale
The Visual Analog Scale is used for older children and adults who can understand and communicate their pain level.
Choice B rationale
The FLACC scale (Face, Legs, Activity, Cry, Consolability) is specifically designed for assessing pain in infants and young children who are unable to communicate their pain verbally.
Choice C rationale
The Oucher scale is used for children aged 3 to 12 years and involves matching facial expressions to a pain level.
Choice D rationale
The Faces scale is used for children aged 3 years and older who can point to a face that best represents their pain level.
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Correct Answer is A
Explanation
Choice A rationale
Administering the medications 5 minutes apart ensures that each medication has enough time to be absorbed without interference from the other. This practice helps to maximize the effectiveness of both medications and reduces the risk of adverse interactions.
Choice B rationale
Touching the tip of the dropper to the sclera of the eye can introduce contaminants and increase the risk of infection. It is important to avoid contact between the dropper and the eye to maintain sterility.
Choice C rationale
Holding pressure on the conjunctival sac for 2 minutes is not necessary for the administration of timolol and pilocarpine eye drops. This practice is more commonly recommended for other types of eye medications to increase absorption.
Choice D rationale
Contact lenses should be removed before administering eye drops to prevent contamination and ensure proper absorption of the medication. Wearing contact lenses during administration can interfere with the effectiveness of the drops.
Correct Answer is D
Explanation
Choice A rationale
Diphenhydramine does not expand blood volume. It is an antihistamine used to prevent allergic reactions.
Choice B rationale
Diphenhydramine does not enhance clotting factors. It is used to manage allergic reactions.
Choice C rationale
While diphenhydramine can help manage fever and chills, its primary purpose before a blood transfusion is to prevent allergic reactions.
Choice D rationale
Administering diphenhydramine before a blood transfusion helps prevent urticaria and other allergic reactions by blocking histamine release. .