A nurse is preparing to perform a dressing change on a preschooler. Which of the following actions should the nurse take to prepare the child for the procedure?

Limit teaching sessions about the procedure to 20 min.

Ask the parents to wait outside the room during the procedure.

Instruct the child in deep-breathing methods prior to the procedure.

Explain in simple terms how the procedure will affect the child.

Answer and Explanation

The Correct Answer is D

Rationale:
A. Limit teaching sessions about the procedure to 20 min: While preschoolers have limited attention spans, the focus should be on using age-appropriate language and explanations rather than strictly timing the teaching session. The quality and clarity of instruction are more important.

B. Ask the parents to wait outside the room during the procedure: Preschoolers often feel safer and more cooperative when a parent is present. Removing parents can increase anxiety and resistance, so parental presence is encouraged.

C. Instruct the child in deep-breathing methods prior to the procedure: Deep-breathing exercises can help with relaxation, but preschoolers may have difficulty understanding or performing them effectively. Simple explanations and reassurance are more appropriate.

D. Explain in simple terms how the procedure will affect the child: Providing a clear, age-appropriate explanation helps the preschooler understand what to expect, reduces fear, and promotes cooperation. Using simple terms tailored to the child’s developmental level is the most effective preparation.

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Correct Answer is A

Explanation

Rationale:
A. Potassium 3.1 mEq/L (3.5 to 5 mEq/L): Hypokalemia increases the risk of digoxin toxicity because low potassium levels enhance digoxin’s effects on the myocardium, potentially leading to arrhythmias and other toxic effects. Monitoring electrolytes is crucial for clients taking digoxin, especially when on diuretics like furosemide.

B. WBC count 12,000/mm³ (5,000 to 10,000/mm³): An elevated WBC may indicate infection or inflammation but does not directly influence digoxin toxicity. This finding requires assessment but is not a risk factor for digoxin-related complications.

C. Fasting glucose 150 mg/dL (74 to 106 mg/dL): Elevated glucose reflects hyperglycemia but does not affect digoxin levels or toxicity risk. It should be managed separately according to the client’s metabolic needs.

D. Triglycerides 140 mg/dL (35 to 135 mg/dL): Mildly elevated triglycerides are a cardiovascular risk factor but do not directly increase the likelihood of digoxin toxicity. Lipid management is a separate consideration.

A. Encourage cultural practices to be incorporated into their care. B. Incorporate hot and cold practices into the client's care. C. Acknowledge that the client may be cared for by a male provider. D. Have the client remove any face coverings to obtain their history.

Correct Answer is A

Explanation

Rationale:
A. Encourage cultural practices to be incorporated into their care: Respecting and incorporating a Muslim client’s cultural and religious practices promotes culturally competent and patient-centered care. This approach fosters trust, comfort, and cooperation between the client and healthcare team.

B. Incorporate hot and cold practices into the client's care: Hot and cold theory is typically associated with Hispanic, Asian, and Middle Eastern folk medicine traditions, but not all Muslim clients follow this practice. Care should be based on the client’s individual beliefs.

C. Acknowledge that the client may be cared for by a male provider: Many Muslim women prefer to be cared for by female providers due to religious and cultural values of modesty. The nurse should make reasonable efforts to accommodate this preference whenever possible.

D. Have the client remove any face coverings to obtain their history: Muslim women who wear a niqab or hijab may choose to keep their face covered for modesty. The nurse should not insist on removal unless necessary for identification or assessment, and even then, it should be done privately with sensitivity to religious beliefs.

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A nurse is preparing to perform a dressing change on a preschooler. Which of the following actions should the nurse take to prepare the child for the procedure?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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