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Choice A reason: Informing the client that consent cannot be withdrawn is incorrect, as clients can revoke consent at any time before or during the procedure. This misrepresents patient rights, making it an unethical and illegal statement for the nurse’s role.
Choice B reason: Identifying risks or discomforts is the surgeon’s responsibility, not the nurse’s, during consent. The nurse verifies understanding and voluntariness, not provides risk details, so this action is outside the nurse’s scope, making it incorrect.
Choice C reason: Ensuring the client understands the procedure and voluntarily agrees is the nurse’s role when witnessing consent. This verifies informed, autonomous decision-making, aligning with legal and ethical standards, making it the correct responsibility for the nurse.
Choice D reason: Providing a detailed surgical technique explanation is the surgeon’s role, not the nurse’s. The nurse ensures comprehension and consent, not technical details, so this action exceeds the nurse’s scope during consent, making it incorrect.
Correct Answer is D
Explanation
Choice A reason: Limiting potassium intake is dangerous with digoxin, as low potassium (hypokalemia) increases the risk of digoxin toxicity by enhancing drug binding to cardiac cells. Adequate potassium levels are critical for safe use, as digoxin affects cardiac contractility, making this instruction incorrect and potentially harmful.
Choice B reason: Repeating a digoxin dose if the child vomits within 1 hour is unsafe without medical consultation, as it risks overdose. Digoxin has a narrow therapeutic index, and toxicity can cause arrhythmias. Parents should contact the provider for guidance, making this instruction incorrect and dangerous.
Choice C reason: Adding digoxin to juice risks inaccurate dosing, as the child may not consume the full amount, leading to underdosing or toxicity if additional doses are given. Precise administration (e.g., via syringe) ensures correct dosing, critical for digoxin’s narrow therapeutic range, making this instruction inappropriate.
Choice D reason: Having the child drink water after digoxin ensures the dose is fully swallowed, preventing loss from spitting or incomplete ingestion. This supports accurate dosing, essential for digoxin’s safe use in heart failure, where it enhances cardiac output. This instruction is safe and effective, making it correct.
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