A nurse is assisting with the collection of a bone marrow specimen from a preschooler. Which of the following actions should the nurse take?

The correct answer is Choice D.

Choice A rationale: Administering an oral corticosteroid is not the first action the nurse should take. Corticosteroids are used to reduce inflammation and itching caused by poison ivy. However, they are usually prescribed if the symptoms are severe or if the rash covers a large area of the body. It’s important to note that corticosteroids can have side effects, especially when used for a long time, so they should be used under the supervision of a healthcare provider.

Choice B rationale: Applying calamine lotion to the affected area can help soothe the skin and relieve itching caused by poison ivy. However, this is not the first action the nurse should take. The first step is to remove the oil from the skin that causes the allergic reaction. Calamine lotion can be applied after the area has been thoroughly washed.

Choice C rationale: Instructing the parent to give the child an oatmeal bath twice daily can help soothe the skin and relieve itching. However, this is not the first action the nurse should take. Similar to calamine lotion, an oatmeal bath can be beneficial after the area has been thoroughly washed to remove the oil from the skin.

Choice D rationale: The first action the nurse should take when caring for a child exposed to poison ivy is to flush the area with cold, running water. This helps to remove the oil (urushiol) from the skin that causes the allergic reaction. It’s important to do this as soon as possible after exposure to help prevent the spread of the oil to other areas of the body or to other people. After flushing the area, the nurse can then apply calamine lotion or recommend an oatmeal bath to help soothe the skin and relieve itching.

Answer: B. Reposition the probe every 2 hours.

Rationale:

• A. Warm the skin prior to probe placement:While cold fingers can lead to inaccurate readings,warming the skin is not an essential step and is not routinely recommended in clinical practice.
• B. Reposition the probe every 2 hours:This iscorrect.Continuous pressure from the probe in one spot can cause skin breakdown and pressure injuries.Repositioning the probe every 2 hours helps to prevent this and ensure accurate readings.
• C. Tape the wire to the palm of the hand:This is incorrect.The pulse oximeter probe should be placed on a vascular site,such as a fingertip or earlobe.Taping the wire to the palm would not provide accurate readings.
• D. Apply the sensor to the index fingernail:This is incorrect.The fingernail does not have sufficient blood flow for accurate pulse oximetry readings.The probe should be placed on the fleshy pad of the fingertip.

Therefore, the most important action for the nurse to take is to reposition the probe every 2 hours to prevent skin breakdown and ensure accurate readings.

Additional Points:

• The nurse should also choose a clean and dry site for probe placement.
• The probe should be snug but not too tight.
• The nurse should monitor the child for signs of skin breakdown,such as redness,swelling,or pain.
• If the child is restless or active,the nurse may need to secure the probe with additional tape or a special wrap.