A nurse is caring for a preschooler who is in an acute care facility. Which of the following actions should the nurse take?

Establish a new routine for the child to follow while in the facility.

Encourage the child to play with toys such as a pounding board.

Use medical terminology when discussing procedures with the child.

Perform the morning assessments when the parent is not in the room.

Answer and Explanation

The Correct Answer is B

A. Establish a new routine for the child to follow while in the facility. - Preschoolers thrive on routines and familiarity, especially in unfamiliar environments like acute care facilities. Therefore, it's essential for the nurse to maintain the child's existing routine as much as possible to provide a sense of security and stability.
B. Encourage the child to play with toys such as a pounding board. - Encouraging play with age-appropriate toys helps promote normalcy, reduce anxiety, and facilitate coping for preschoolers during their hospital stay. Toys like a pounding board provide opportunities for physical activity and engagement, which can help distract and entertain the child.
C. Use medical terminology when discussing procedures with the child. - Preschoolers have limited understanding of complex medical terminology. Using simple, age-appropriate language helps the child better comprehend what is happening, reducing fear and anxiety. Therefore, it's important for the nurse to avoid medical jargon and use language the child can understand.
D. Perform the morning assessments when the parent is not in the room. - Preschoolers often feel more comfortable and secure when their parents are present, especially in unfamiliar environments like hospitals. Performing assessments in the presence of the parent helps maintain the child's sense of security and allows the parent to participate in the child's care and provide comfort and support.

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Correct Answer is A

Explanation

A. Measure the legs with a tape measure to determine stocking size: Antiembolic stockings should fit properly to provide therapeutic compression without causing discomfort or impairing circulation. Measuring the legs accurately with a tape measure ensures the stockings fit appropriately and exert the correct amount of pressure to prevent deep vein thrombosis (DVT) and promote venous return.
B. Remove the stockings every 24 hr: Antiembolic stockings are typically worn continuously, especially during periods of immobility, to maintain consistent compression and prevent blood clots. Removing the stockings every 24 hours would interrupt the therapeutic effect and increase the client's risk of developing DVT.
C. Massage the legs before applying the stockings: Massaging the legs before applying antiembolic stockings is contraindicated, as it can dislodge blood clots and increase the risk of embolism. Additionally, massaging may cause trauma to the skin and exacerbate any existing circulatory issues.
D. Fold the stockings at the top if they are too long: Folding the stockings at the top if they are too long can create pressure points and compromise circulation, leading to discomfort and potentially exacerbating vascular issues. It is essential to ensure the stockings fit properly by selecting the appropriate size rather than folding them.

A. Obtain urinary samples by disconnecting the tubing connections. B. Secure the catheter to the client's thigh. - C. Keep the urinary bag at bladder level when ambulating. D. Loop the tubing so that it is lower than the collection bag.

Correct Answer is B

Explanation

A. Obtain urinary samples by disconnecting the tubing connections:
This action increases the risk of contamination and introduces bacteria into the urinary system, potentially leading to UTIs. Urine samples should be obtained using a sterile technique to minimize the risk of infection.

B. Secure the catheter to the client's thigh:
Securing the catheter to the client's thigh can cause tension and traction on the catheter, increasing the risk of urethral trauma and introducing bacteria into the urinary tract. Catheters should be secured without tension to prevent damage to the urethra and reduce the risk of UTIs.

C. Keep the urinary bag at bladder level when ambulating:
Keeping the urinary bag at bladder level when ambulating prevents urine from flowing back into the bladder, reducing the risk of UTIs. Gravity drainage helps maintain the flow of urine and prevents stasis, which can contribute to bacterial growth and UTIs.

D. Loop the tubing so that it is lower than the collection bag:
Looping the tubing so that it is lower than the collection bag creates a dependent loop where urine can accumulate, increasing the risk of bacterial colonization and UTIs. The tubing should be kept straight and free of kinks to ensure continuous drainage and prevent urine from pooling in the tubing.

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A nurse is caring for a preschooler who is in an acute care facility. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has deep-vein thrombosis and a new prescription for antiembolic stockings. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

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Correct Answer is B

Explanation

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