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 C
Explanation
Choice A rationale:
Placing the infant in a supine position during naps might not be the best action for an infant with heart failure. In heart failure, infants often experience difficulty breathing due to fluid accumulation in the lungs. Placing the infant in a more upright position, such as semi-Fowler's, can help alleviate some of this respiratory distress.
Choice B rationale:
Feeding the infant a bottle every 4 hours is important, but it might not directly address the immediate concerns of an infant with heart failure. Infants with heart failure might have difficulty feeding due to fatigue and respiratory distress. Feeding smaller, more frequent meals and assessing the infant's feeding tolerance is crucial.
Choice C rationale:
Correct Answer. Documenting the infant's respiratory rate every 2 hours is an important action. Infants with heart failure often have respiratory distress and an increased respiratory rate, as the body tries to compensate for decreased cardiac output. Documenting the respiratory rate will help the healthcare team monitor the infant's condition and assess the effectiveness of interventions.
Choice D rationale:
Withholding digoxin if the infant's heart rate is greater than 100/min is not necessarily the correct action. Digoxin is a medication commonly used in heart failure to improve cardiac contractility. While it's important to monitor the infant's heart rate, a heart rate of greater than 100/min might be due to the body's compensatory mechanisms in response to heart failure. Withholding the medication without consulting a healthcare provider might not be appropriate.
Correct Answer is A
Explanation
Choice A rationale:
Maintaining oral rehydration therapy is a crucial nursing action when caring for a child with shigella, which is a bacterial infection that causes severe diarrhea. Oral rehydration therapy helps prevent dehydration and electrolyte imbalances caused by fluid loss from diarrhea. It involves giving the child oral rehydration solutions containing electrolytes and fluids to replace those lost through diarrhea.
Choice B rationale:
Providing a diet high in sodium is not recommended for a child with shigella. Shigella is associated with diarrhea and gastrointestinal symptoms, and a high-sodium diet can worsen fluid imbalances and dehydration.
Choice C rationale:
Shigella is a bacterial infection, not a viral infection, so administering antiviral medication would not be effective or appropriate. Antiviral medications are used to treat viral infections, not bacterial ones like shigella.
Choice D rationale:
Giving antidiarrheal agents every 4 hours is not recommended for a child with shigella. Antidiarrheal agents can slow down the gastrointestinal tract and inhibit the body's natural mechanism for expelling harmful substances, such as bacteria. It's important to allow the body to eliminate the bacteria and toxins causing the infection through diarrhea, while simultaneously providing rehydration support.
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