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 C
Explanation
Rationale:
A. "This medication can cause back pain.": Back pain is not a common or expected adverse effect of warfarin. Teaching should focus on bleeding risks and precautions rather than unrelated symptoms.
B. "Avoid taking this medication with milk products.": Milk does not significantly affect warfarin absorption. The main dietary consideration is maintaining consistent vitamin K intake, as large fluctuations can alter anticoagulation.
C. "Use an electric razor when shaving while taking this medication.": Warfarin increases the risk of bleeding and bruising. Using an electric razor reduces the chance of cuts, promoting safety during routine grooming.
D. "Avoid prolonged exposure to sunlight while taking this medication.": Sun exposure is not contraindicated with warfarin; there is no significant interaction between warfarin and UV light.
Correct Answer is B
Explanation
Rationale:
A. Educate clients who are at risk for Parkinson's disease about maintaining a low-cholesterol diet: This is an example of primary prevention, aimed at reducing risk factors before the onset of disease, rather than tertiary prevention.
B. Provide daily exercise classes to improve ambulation for patients who have Parkinson's disease: Tertiary prevention focuses on managing disease, minimizing complications, and improving quality of life for those already diagnosed. Exercise programs help maintain mobility and prevent further functional decline.
C. Educate clients about common techniques used to diagnose Parkinson's disease: Teaching about diagnostic techniques is related to secondary prevention, which focuses on early detection and timely intervention.
D. Provide screenings for community members to identify early manifestations of Parkinson's disease: Screening is a secondary prevention strategy intended to detect disease early in asymptomatic individuals, not tertiary prevention.
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