A nurse is preparing to obtain a blood specimen from a preschooler. Which of the following actions should the nurse perform?
Collect 4 mL/kg of blood in a 24-hr period.
Apply lidocaine cream 30 min prior to collecting the specimen.
Ask the parents to leave the room prior to collecting the blood specimen.
Demonstrate the use of the equipment to the child.
The Correct Answer is D
Rationale:
A. Collect 4 mL/kg of blood in a 24-hr period: This volume exceeds safe limits for blood collection in small children. The guideline is not to exceed 3 mL/kg over 24 hours unless clinically necessary, as excessive draws can lead to anemia or hemodynamic instability.
B. Apply lidocaine cream 30 min prior to collecting the specimen: While lidocaine-prilocaine cream can be helpful, it typically requires at least 60 minutes to achieve adequate dermal analgesia. Applying it for only 30 minutes may not be sufficient to reduce pain effectively.
C. Ask the parents to leave the room prior to collecting the blood specimen: Parents are often a source of comfort and reassurance for preschoolers. Unless their presence is disruptive, involving them in the process can help calm the child and improve cooperation.
D. Demonstrate the use of the equipment to the child: Preschoolers benefit from age-appropriate explanations and demonstrations. Showing them the equipment reduces fear and anxiety by promoting familiarity and a sense of control in an unfamiliar situation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Rationale:
A. “You can obtain a personal response system that will be activated if you fall.": Personal emergency response systems (PERS) allow individuals who live alone to call for help immediately in case of a fall or emergency.
B. “You need to move to a skilled nursing facility where they can prevent falls.": Moving to a skilled nursing facility is a major step and is not necessary solely due to fear of falling. It may also provoke anxiety or feelings of loss of autonomy, especially if less invasive alternatives are available.
C. "You can have an unlicensed assistive personnel (UAP) come to your house daily to stay with you.": Daily UAP support may not be realistic or necessary for someone who is still generally independent. This level of care may be excessive unless the client has significant mobility or cognitive impairments.
D. "You should contact a family member once a week to keep in touch.": While weekly contact with family can offer emotional support, it does not provide real-time assistance in the event of a fall. It’s not a sufficient solution for immediate safety concerns.
Correct Answer is ["D","E"]
Explanation
Rationale:
A. Check for a disconnection in the ventilator tubing: A disconnection typically causes a low-pressure alarm, not an increase in peak airway pressure, and would not be the appropriate first response in this case.
B. Assess the ET for a cuff leak: A cuff leak would decrease airway pressure, potentially causing a low-pressure alarm. It is not associated with increased peak airway pressure alarms.
C. Verify the placement of the ET: ET tube misplacement can lead to ventilation issues, but it does not directly cause increased peak pressures unless malposition leads to obstruction, which would be less common.
D. Check for a kink in the ventilator tubing: A kink or obstruction in the tubing increases airway resistance and can cause high peak airway pressure alarms. Resolving the kink can restore normal pressure.
E. Suction the ET to remove secretions: Mucus plugging or secretion buildup increases resistance in the airway, raising peak pressures. Suctioning helps alleviate the obstruction and reduce alarm triggers.
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