A nurse is assisting with preparing a toddler for an intravenous procedure.
Which of the following actions should the nurse take? (Select all that apply)

Choice A rationale

Applying suction continuously while inserting the suction catheter is not recommended. This could potentially cause trauma to the trachea and lead to complications.

Choice B rationale

Using a large diameter suction catheter for better suctioning is not recommended. The size of the suction catheter should be appropriate for the size of the tracheostomy tube. Using a catheter that is too large could cause trauma to the trachea.

Choice C rationale

Suctioning for no more than 10 seconds at a time is recommended to prevent hypoxia (lack of oxygen). Prolonged suctioning can lead to complications such as hypoxia, trauma to the trachea, and cardiac arrhythmias.

Choice D rationale

Applying suction while the child is exhaling is not recommended. Suction should be applied while withdrawing the suction catheter, not during exhalation.

Choice A rationale

The FACES pain scale is typically used for children who are at least 3 years old. It requires the child to compare their pain to a series of faces ranging from smiling to crying.

Choice B rationale

The Word-Graphic Rating Scale is typically used for older children and adolescents who can read and understand the descriptive words associated with each level of pain.

Choice C rationale

The FLACC pain scale, which stands for Face, Legs, Activity, Cry, and Consolability, is appropriate for assessing pain in a 3-month-old infant. It is often used for children under 3 years old or those who are unable to verbally communicate their pain.

Choice D rationale

The Oucher pain scale is typically used for children aged 3 to 13 years. It includes a series of photographs of children’s faces and a numerical scale for older children.