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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.

Answer and Explanation

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.

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Correct Answer is D

Explanation

A history of frequent urinary tract infections (UTIs) is a sign of child maltreatment. It may indicate sexual abuse, which can introduce bacteria into the urinary tract.Sexual abuse may also cause genital or anal trauma, sexually transmitted infections, or pregnancy 1. UTIs are uncommon in children, especially in boys.The normal frequency of UTIs in children is around 1 in 10 girls and 1 in 30 boys by the age of 16 years

A. Headache. B. Negative Kernig sign. C. Vomiting. D. Seizures. E. Tinnitus.

Correct Answer is ["A","B","C","D"]

Explanation

Choice A rationale:
Headache is an expected finding in a school-age child with bacterial meningitis. Bacterial meningitis is an inflammation of the meninges, and the membranes surrounding the brain and spinal cord, often caused by bacteria. The inflammatory process can lead to increased intracranial pressure, which commonly presents as a headache. This headache is often severe and can be accompanied by other symptoms like fever, irritability, and sensitivity to light.
Choice B rationale:
A negative Kernig sign is a possible finding in a school-age child with bacterial meningitis. Kernig sign is a clinical test performed to assess for meningitis. A positive Kernig sign is characterized by resistance and pain in extending the knee when the hip is flexed at a 90-degree angle. However, a negative Kernig sign does not rule out meningitis, as it might not always be present.
Choice C rationale:
Vomiting is an expected finding in a school-age child with bacterial meningitis. The increase in intracranial pressure due to inflammation of the meninges can lead to nausea and vomiting. The vomiting is often projectile and may not be relieved by eating or drinking.
Choice D rationale:
Seizures are an expected finding in a school-age child with bacterial meningitis. The inflammation of the brain and meninges can irritate the brain tissue and trigger seizures. Seizures in the context of bacterial meningitis might be generalized or focal in nature.
Choice E rationale:
Tinnitus (ringing in the ears) is not a typical finding associated with bacterial meningitis. The main symptoms of bacterial meningitis are related to the central nervous system and meningeal irritation, such as headache, fever, neck stiffness, and neurological changes. Tinnitus is not a common manifestation of bacterial meningitis and is not part of the typical clinical picture.

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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?

Answer: B. Reposition the probe every 2 hours.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is ["A","B","C","D"]

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