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 B
Explanation
Choice A rationale:
Administer pain medication. Administering pain medication is important for the preschooler's comfort, but it is not the nurse's priority action in this scenario. The priority is to ensure adequate circulation to the extremities, which can be assessed by checking capillary refill.
Choice B rationale:
Check capillary refill. This is the correct answer because the nurse's priority is to assess the child's circulation and tissue perfusion. In 90-90 traction, there is a risk of impaired circulation to the extremities due to the positioning. Checking capillary refill provides information about the adequacy of blood flow to the capillaries and is crucial for early detection of any circulation problems.
Choice C rationale:
Cleanse and dress the pin sites. While caring for the pin sites is important to prevent infection, it is not the priority action at this moment. Ensuring proper circulation and perfusion takes precedence over pin site care.
Choice D rationale:
Reposition the child every 2 hr. Repositioning the child is important to prevent complications associated with immobility, but it is not the nurse's priority action in this situation. The primary concern is to assess and address any circulation issues.
Correct Answer is B
Explanation
Choice A rationale:
Avoiding discussions about the child's diagnosis with the sibling might create confusion and anxiety for the sibling. Open communication is essential for helping siblings understand their brother or sister's condition and cope with the changes in the family dynamic.
Choice B rationale:
Encouraging phone calls between the siblings is a positive step in promoting sibling adaptation when one of them has a chronic illness like cystic fibrosis. Maintaining connections through communication helps siblings feel involved, valued, and informed about each other's lives and challenges.
Choice C rationale:
Designating one parent to stay at home with the sibling might lead to feelings of isolation and neglect for the child with cystic fibrosis. Siblings also need support and attention during this time, and isolating one parent could hinder healthy sibling relationships.
Choice D rationale:
Avoiding having the sibling visit the child in the facility may prevent the sibling from understanding the condition and create a sense of fear or confusion. Controlled, supervised visits can actually be beneficial, as they allow the siblings to interact and support each other in a safe environment.
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