Thirty minutes after receiving meperidine, the client develops a temperature of 101°F and the skin is warm and flushed with a notable rash on the chest and back. The nurse contacts the primary health care provider and begins to document on an incident report. Which information should be included?
The client had an allergic reaction to the ordered meperidine.
The primary health care provider was notified because the client developed a rash after receiving an opioid analgesic.
The client’s skin was warm and flushed, and a rash was noted on the chest and back.
Thirty minutes after receiving meperidine, the temperature was 101°F (38.3°C).
The Correct Answer is D
Choice A rationale
Stating that the client had an allergic reaction to the ordered meperidine is not objective and does not provide specific details about the client’s condition.
Choice B rationale
Notifying the primary health care provider because the client developed a rash after receiving an opioid analgesic is important, but it does not include all the necessary details about the client’s condition.
Choice C rationale
Documenting that the client’s skin was warm and flushed, and a rash was noted on the chest and back is important, but it does not include the timing of the reaction or the client’s temperature.
Choice D rationale
Documenting that thirty minutes after receiving meperidine, the temperature was 101°F (38.3°C), the client’s skin was warm and flushed, and a rash was noted on the chest and back provides a complete and objective account of the client’s condition and the timing of the reaction.
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Correct Answer is ["A","C"]
Explanation
Choice A rationale
The use of silicone-based vaginal lubricants is recommended for clients with Sjögren’s syndrome to alleviate vaginal dryness and discomfort during intercourse.
Choice B rationale
Using dehumidifiers in the home is not recommended for clients with Sjögren’s syndrome, as it can exacerbate dryness in the eyes, mouth, and other mucous membranes.
Choice C rationale
The use of artificial tears is essential for clients with Sjögren’s syndrome to relieve dry eyes and prevent complications such as corneal ulcers.
Choice D rationale
The use of contact lenses is not recommended for clients with Sjögren’s syndrome, as it can further irritate dry eyes and increase the risk of eye infections.
Correct Answer is B
Explanation
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.