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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Rationale:
A. How to change the tracheostomy dressing using clean technique: Tracheostomy dressings should be changed using sterile technique, not clean technique, to prevent infection and protect the airway. Teaching clean technique would be inappropriate.
B. How to operate the portable suction machine: Suctioning is a critical skill for maintaining airway patency and preventing respiratory complications. Teaching the partner how to operate the suction machine ensures they can assist safely at home if needed.
C. How to change the nondisposable tracheostomy tube daily: Nondisposable tracheostomy tubes are not typically changed daily; frequent changes can damage the stoma or airway. Tube changes are usually performed by trained healthcare personnel.
D. How to secure the tracheostomy tube with ties at the back of the neck: Ties should be secured in a way that avoids pressure or friction on the back of the neck, typically fastening at the sides. Focusing on back-of-neck placement could lead to skin breakdown or discomfort.
Correct Answer is C
Explanation
A. Remind the client to eat scheduled meals daily: Clients nearing the end of life often have a decreased appetite and may be unable or unwilling to eat. Forcing meals can cause discomfort and is not a priority at this stage.
B. Place the client in a supine position: Lying flat can increase the risk of aspiration and respiratory discomfort. Positioning the client for comfort, often semi-Fowler’s or side-lying, is preferred.
C. Offer the client a blanket to keep warm: Clients near the end of life may experience chills or cool extremities due to decreased circulation. Providing a blanket helps maintain comfort and dignity, which is a primary goal of end-of-life care.
D. Speak in a loud tone when addressing the client: Speaking loudly is unnecessary unless the client has hearing impairment. Communication should remain calm, gentle, and respectful to provide reassurance and maintain comfort.
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