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 C
Explanation
Choice A reason: Keeping the drainage bag above waist level promotes urine backflow, increasing infection risk. Bags must be below bladder level to ensure proper urine flow, so this action is incorrect and unsafe, requiring nurse intervention.
Choice B reason: Disconnecting the catheter to empty the bag breaks the closed system, increasing infection risk. The bag should be emptied via the drainage port, so this action is incorrect and requires correction by the nurse.
Choice C reason: Emptying the drainage bag when three-quarters full prevents overfilling, reducing backflow and infection risk. This aligns with proper catheter care protocols, ensuring safety for a fall-risk client, making it the correct technique.
Choice D reason: Using sterile gloves for emptying the drainage bag is unnecessary, as clean gloves suffice for this non-sterile procedure. Sterile gloves are for catheter insertion, so this action is incorrect and inefficient, requiring guidance.
Correct Answer is ["A","C","E"]
Explanation
Choice A reason: Hypothermia increases metabolic demand in newborns, depleting glucose stores rapidly. Neonates have limited glycogen reserves, and cold stress accelerates glucose use for thermogenesis, risking hypoglycemia. This is critical in nurseries, as thermoregulation is essential to prevent metabolic imbalances in vulnerable infants.
Choice B reason: Thrombocytopenia, low platelet count, affects clotting, not glucose metabolism. It may occur in sepsis but does not directly cause hypoglycemia. Glucose regulation depends on liver function and insulin balance, not platelets, making this irrelevant to hypoglycemia risk in newborns.
Choice C reason: Prematurity heightens hypoglycemia risk due to immature liver glycogen stores and limited gluconeogenesis. Preterm infants have high metabolic demands and low reserves, increasing susceptibility to low blood glucose, necessitating close monitoring and early feeding to stabilize glucose levels.
Choice D reason: Anemia, low red blood cell count, impacts oxygen delivery but not glucose metabolism directly. Severe anemia may increase metabolic stress, but it is not a primary hypoglycemia cause. Glucose regulation relies on hepatic and insulin functions, not hematologic status, in newborns.
Choice E reason: Maternal diabetes causes fetal hyperinsulinemia from maternal hyperglycemia, leading to neonatal hypoglycemia post-birth. Excess insulin depletes glucose stores after umbilical cord clamping, as maternal glucose supply ceases, making this a critical risk factor requiring vigilant monitoring in newborns.
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