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?
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.
Limit teaching sessions about the procedure to 20 minutes.
The Correct Answer is C
Choice A reason: Asking parents to wait outside may increase the preschooler’s anxiety, as parental presence provides comfort. Unless clinically necessary, excluding parents is not ideal, so this action is inappropriate for preparing the child, making it incorrect.
Choice B reason: Teaching deep-breathing to a preschooler is challenging due to their developmental stage, and it may not effectively reduce anxiety for a dressing change. Simpler reassurance is more suitable, so this is less effective, making it incorrect.
Choice C reason: Explaining the procedure in simple terms helps the preschooler understand what to expect, reducing fear and promoting cooperation. This developmentally appropriate approach aligns with pediatric care principles, making it the correct action for preparation.
Choice D reason: Limiting teaching to 20 minutes is impractical for a preschooler, whose attention span is short. Brief, simple explanations are more effective, and prolonged sessions may overwhelm the child, so this is incorrect for preparing them.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Offering the breast at hunger cues, like rooting, supports demand feeding, regulating milk supply via prolactin. This ensures adequate nutrition and bonding, critical for infant growth and lactation success, aligning with evidence-based breastfeeding practices for optimal maternal-infant outcomes.
Choice B reason: Limiting feeding to 10 minutes per breast restricts hindmilk intake, rich in fat, reducing nutrition and milk supply. Fixed timing disrupts prolactin-driven lactation, risking inadequate weight gain, contrary to breastfeeding guidelines recommending unrestricted feeding based on infant cues.
Choice C reason: Starting each feeding with the same breast risks unbalanced milk production and engorgement. Alternating breasts ensures even stimulation and emptying, maintaining supply and preventing complications, making this incorrect for supporting effective breastfeeding practices in new parents.
Choice D reason: Feeding every 6 hours is too infrequent for newborns, needing feeds every 2-3 hours to meet nutritional demands and stimulate milk production. Fixed schedules ignore hunger cues, risking dehydration or poor growth, contradicting evidence-based breastfeeding recommendations for infants.
Correct Answer is A
Explanation
Choice A reason: A BMI of 32 indicates obesity, a risk factor for surgical wound infections due to impaired tissue perfusion, reduced immune response, and prolonged healing. Excess adipose tissue increases infection likelihood, aligning with evidence-based risk factors, making this the correct finding to identify.
Choice B reason: A temperature of 36.8°C is normal and does not indicate infection risk. Fever (>38°C) post-surgery might suggest infection, but this value reflects stable physiology, making it an incorrect indicator for assessing wound infection risk in this client.
Choice C reason: A white blood cell count of 8,000/mm³ is within normal range (5,000-10,000/mm³) and does not indicate infection risk. Elevated counts suggest active infection, but this value is unremarkable, making it incorrect for identifying infection risk post-surgery.
Choice D reason: A blood glucose of 90 mg/dL is normal (74-106 mg/dL) and does not increase infection risk. Hyperglycemia (>140 mg/dL) impairs immune function, but this value indicates good control, making it incorrect for assessing wound infection risk.
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