A nurse on a pediatric unit is preparing to insert an IV catheter for a 7-year-old child who is dehydrated. Which of the following actions should the nurse take?
Use a mummy restraint to hold the child during the catheter insertion.
Perform the procedure in the child's room.
Require the parents to leave the room during the procedure.
Tell the child there will be discomfort during the catheter insertion.
The Correct Answer is B
Rationale:
A. Use a mummy restraint to hold the child during the catheter insertion: Physical restraints should be used only as a last resort, as they can increase anxiety and trauma. Non-pharmacologic methods and parental support are preferred for safely holding a child during procedures.
B. Perform the procedure in the child's room: Conducting the IV insertion in the child’s room helps reduce stress by providing a familiar environment. It also allows parental presence, which can comfort the child and improve cooperation.
C. Require the parents to leave the room during the procedure: Removing parents can increase the child’s anxiety and reduce emotional support. Parental presence is generally encouraged to help the child feel safe during invasive procedures.
D. Tell the child there will be discomfort during the catheter insertion: The nurse should provide age-appropriate explanations using simple, honest language, focusing on sensations rather than labeling it as painful, to reduce fear and encourage cooperation.
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Related Questions
Correct Answer is D
Explanation
A. Educate a client about the purpose of a sputum specimen: Client education requires nursing knowledge and judgment to explain procedures, answer questions, and evaluate understanding. This cannot be delegated to assistive personnel.
B. Perform irrigation of an indwelling urinary catheter: Catheter irrigation is a sterile invasive procedure that requires nursing skill to prevent infection and complications. It falls outside the scope of assistive personnel.
C. Administer liquid aspirin to a client who is crying: Medication administration involves assessment, calculation, and monitoring for adverse effects, which are responsibilities of a licensed nurse. Assistive personnel cannot administer medications.
D. Provide a bed bath for a client who requires isolation precautions: Assisting with hygiene is within the scope of assistive personnel. They can safely provide a bed bath while following isolation protocols under the supervision of the nurse.
Correct Answer is A
Explanation
Rationale:
A. Maintain the irrigation solution rate: Pink-tinged urine is expected in the early hours after a TURP due to residual bleeding from the surgical site. The nurse should continue the current irrigation rate to prevent clot formation and maintain catheter patency.
B. Warm the irrigation solution: Warming the solution is not required for bladder irrigation and does not address the normal postoperative finding of pink-tinged urine. It also does not play a role in preventing clot formation.
C. Perform the Credé's maneuver: This technique, involving manual bladder compression, is not appropriate for a client with a continuous bladder irrigation and indwelling catheter in place. It could cause injury or disrupt the surgical site.
D. Replace the indwelling urinary catheter: There is no indication of catheter blockage or malfunction in this scenario. Replacing the catheter unnecessarily increases infection risk and could damage the urethra or surgical area.
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