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 C

Explanation

Rationale:
A. "I will take a bulk-forming laxative every day.": While bulk-forming laxatives can help manage constipation, taking them without adequate fluid intake can worsen constipation or cause bowel obstruction. Education should emphasize combining fiber with sufficient fluids.

B. "I will avoid strenuous exercise.": Regular physical activity actually promotes intestinal motility and helps prevent opioid-induced constipation. Avoiding exercise would counteract this preventive strategy.

C. "I will increase my intake of high-fiber foods.": Consuming high-fiber foods, such as fruits, vegetables, and whole grains, adds bulk to stool and promotes regular bowel movements. This is a key dietary intervention for preventing constipation in clients taking opioids like oxycodone.

D. "I will limit my fluid intake to 1 liter per day.": Limiting fluids can exacerbate constipation because hydration is necessary to soften stool and support normal bowel function. Clients should maintain adequate fluid intake alongside increased dietary fiber.

A. Initiate fibrinolytic therapy. B. Place the client in a supine position. C. Prepare the client for a chest x-ray. D. Insert an indwelling urinary catheter.

Correct Answer is A

Explanation

Rationale:
A. Initiate fibrinolytic therapy: Fibrinolytic therapy, such as tissue plasminogen activator (tPA), is most effective when administered within a 3- to 4.5-hour window from the onset of ischemic stroke symptoms. Early administration can dissolve the clot, restore cerebral blood flow, and improve neurological outcomes.

B. Place the client in a supine position: Clients with ischemic stroke are usually positioned with the head of the bed elevated 15–30 degrees unless contraindicated. Supine positioning can increase intracranial pressure and risk aspiration, which may worsen neurological status.

C. Prepare the client for a chest x-ray: A chest x-ray is not a priority in acute ischemic stroke management. Immediate neuroimaging, typically a CT scan, is required to differentiate ischemic from hemorrhagic stroke before initiating fibrinolytic therapy.

D. Insert an indwelling urinary catheter: Inserting a catheter is not indicated as an initial intervention for acute stroke unless the client is unable to void or requires strict output monitoring. Priority actions focus on neuroprotection and reperfusion therapy.

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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 C

Explanation

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Correct Answer is A

Explanation

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