A nurse is caring for a school-age child who has a new prescription for continuous pulse oximetry monitoring. Which of the following actions should the nurse take?
Warm the skin prior to probe placement.
Reposition the probe every 2 hr.
Tape the wire to the palm of the hand.
Apply the sensor to the index fingernail.
The Correct Answer is B
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 is correct. 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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
Occupational therapy is the appropriate referral for an adolescent with rheumatoid arthritis who is having difficulty feeding themselves. Rheumatoid arthritis is a chronic autoimmune disorder that can lead to joint inflammation and deformities. Occupational therapy focuses on helping individuals improve their ability to perform daily activities, which includes activities like feeding, dressing, and grooming. Occupational therapists work with patients to develop strategies and use adaptive equipment to make these tasks more manageable. In the case of an adolescent with rheumatoid arthritis, occupational therapy can provide techniques and tools to facilitate feeding independently despite joint limitations.
Choice B rationale:
Physical therapy primarily focuses on improving mobility, strength, and function in individuals with musculoskeletal issues. While physical therapy could be beneficial for an adolescent with rheumatoid arthritis to address joint mobility and muscle strength, it might not directly address the difficulty in feeding. Therefore, although physical therapy can be a helpful component of care for patients with rheumatoid arthritis, it might not be the first choice for addressing feeding difficulties.
Choice C rationale:
Speech therapy is not the most appropriate referral for an adolescent with rheumatoid arthritis experiencing feeding difficulties. Speech therapy primarily addresses communication and swallowing disorders. While swallowing difficulties might be relevant in some cases of rheumatoid arthritis due to potential joint involvement in the jaw, the primary focus should be on addressing joint limitations and adaptive techniques for feeding, making occupational therapy a more suitable referral.
Choice D rationale:
A case manager is not the recommended referral for an adolescent with rheumatoid arthritis and feeding difficulties. Case managers typically coordinate and facilitate various aspects of a patient's care, such as arranging appointments and services. While case managers play a valuable role in healthcare, the immediate concern of feeding difficulties in an adolescent with rheumatoid arthritis is best addressed through specialized interventions like occupational therapy.
Correct Answer is C
Explanation
Choice A rationale:
Perfectionistic behavior is not typically considered a behavioral finding indicative of sexual abuse in a school-age child. Perfectionism may be related to personality traits, family dynamics, or individual tendencies, but it is not a specific behavioral marker for sexual abuse.
Choice B rationale:
Manipulative behavior is not a specific indicator of sexual abuse in a school-age child. Children can display manipulative behavior for various reasons, including seeking attention or attempting to control situations. While behavioral changes can occur in response to trauma, manipulative behavior alone does not necessarily point to sexual abuse.
Choice C rationale:
Withdrawn behavior is a possible indication of sexual abuse in a school-age child. Sexual abuse can cause emotional and psychological distress in children, leading them to withdraw from social interactions. They might become isolated, exhibit changes in their usual behavior, and show decreased interest in activities they previously enjoyed.
Choice D rationale:
Destructive behavior is not a prominent behavioral finding associated specifically with sexual abuse in a school-age child. Destructive behaviors can arise from a range of factors, including emotional difficulties, behavioral disorders, or reactions to stressors. While trauma like sexual abuse can influence behavior, it's not a defining characteristic of sexual abuse in isolation.
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