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 D
Explanation
The correct answer is choice D, wooden building blocks.
Choice A rationale:
Colored paper and safety scissors are not appropriate for an 18-month-old child due to safety concerns. At this age, children are still developing fine motor skills and coordination, and the use of scissors, even safety ones, poses a risk of injury.
Choice B rationale:
Stringing beads is not suitable for an 18-month-old child as it requires more advanced fine motor skills and could pose a choking hazard. Children at this age are still prone to exploring objects by putting them in their mouths.
Choice C rationale:
Alphabet flash cards are not the best choice for an 18-month-old child with pneumonia. While flash cards can be educational, they are more suited for older children who are beginning to learn letters and words. At 18 months, play should focus on sensory and motor skill development rather than academic learning.
Choice D rationale:
Wooden building blocks are the most appropriate choice for an 18-month-old child. They encourage play that is developmentally supportive, promoting fine motor skills and creativity. Blocks can be easily handled by small hands, and there is no risk of injury or choking. Additionally, building and knocking down block towers can provide a sense of accomplishment and enjoyment for the child.
Correct Answer is D
Explanation
Choice A rationale:
Tinnitus is the perception of noise or ringing in the ears. It can be caused by various factors, including exposure to loud noises, ear infections, and certain medications. However, tinnitus is not a commonly reported adverse effect of albuterol, which is a bronchodilator used to treat conditions like asthma and other respiratory disorders.
Choice B rationale:
Constipation is not a commonly reported adverse effect of albuterol. Albuterol primarily acts on the smooth muscles of the airways to relax and dilate them, improving airflow. Constipation is more likely related to issues with the gastrointestinal system or certain medications, but it is not a direct consequence of albuterol use.
Choice C rationale:
Hypoglycemia, or low blood sugar, is not a known adverse effect of albuterol. Albuterol primarily affects the respiratory system and does not typically impact blood glucose levels. Hypoglycemia is more commonly associated with diabetes medications like insulin or certain oral hypoglycemic agents.
Choice D rationale:
Headache is a potential adverse effect of albuterol. While not everyone will experience a headache when taking albuterol, it can occur as a side effect in some individuals. Albuterol can stimulate the sympathetic nervous system, leading to effects such as increased heart rate and potential vasodilation, which could contribute to the development of a headache in some cases. It's important for the parents of a child taking albuterol to be aware of potential side effects and report them to the healthcare provider if they occur.
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