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Administering an oral corticosteroid is not the first action the nurse should take. Corticosteroids are used to reduce inflammation and itching caused by poison ivy. However, they are usually prescribed if the symptoms are severe or if the rash covers a large area of the body. It’s important to note that corticosteroids can have side effects, especially when used for a long time, so they should be used under the supervision of a healthcare provider.

Applying calamine lotion to the affected area can help soothe the skin and relieve itching caused by poison ivy. However, this is not the first action the nurse should take. The first step is to remove the oil from the skin that causes the allergic reaction. Calamine lotion can be applied after the area has been thoroughly washed.

Instructing the parent to give the child an oatmeal bath twice daily can help soothe the skin and relieve itching. However, this is not the first action the nurse should take. Similar to calamine lotion, an oatmeal bath can be beneficial after the area has been thoroughly washed to remove the oil from the skin.

While saline instillations may be used in some cases,it is not universally recommended for infants with tracheostomies and depends on the specific situation and healthcare provider's protocol.The priority in this case is to quickly clear the partial mucus occlusion to prevent respiratory distress.

This isincorrect.Selecting a catheter that fits tightly can damage the delicate tracheal mucosa and increase the risk of bleeding.A smaller-diameter catheter that allows for gentle passage is preferred.

This is absolutely essential for all suctioning procedures to minimize the risk of infection.However,it is not the specific action that addresses the immediate concern of clearing the partial mucus occlusion.

While cold fingers can lead to inaccurate readings,warming the skin is not an essential step and is not routinely recommended in clinical practice.

This is incorrect.The pulse oximeter probe should be placed on a vascular site,such as a fingertip or earlobe.Taping the wire to the palm would not provide accurate readings.

This is incorrect.The fingernail does not have sufficient blood flow for accurate pulse oximetry readings.The probe should be placed on the fleshy pad of the fingertip.

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Extremities warm to touch. This manifestation is not indicative of decreased cardiac output. Warm extremities suggest adequate peripheral perfusion and circulation. In a child with decreased cardiac output, the body might attempt to shunt blood away from the extremities to prioritize vital organs, leading to cooler extremities.

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Capillary refill 2 seconds. A capillary refill time of 2 seconds is within the normal range for a preschool-aged child. This quick capillary refill suggests adequate circulation and is not a sign of decreased cardiac output. Prolonged capillary refill time might be indicative of poor peripheral perfusion.

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Blood pressure 112/66 mm Hg. While a blood pressure of 112/66 mm Hg might be within the normal range for a preschooler, it is not the most reliable indicator of decreased cardiac output. Blood pressure can be influenced by various factors, and a seemingly normal blood pressure does not rule out decreased cardiac output if other manifestations are present.

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Urine osmolality 500 mOsm/kg. Urine osmolality is a measure of urine concentration and is not a reliable indicator of infection. It reflects the kidney's ability to concentrate urine and can vary based on hydration status and other factors. An elevated urine osmolality could suggest dehydration, not necessarily infection.

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BUN 12 mg/dL. Blood Urea Nitrogen (BUN) measures kidney function and hydration status. While an elevated BUN can indicate dehydration, it is not a specific marker for infection. BUN levels can be influenced by various factors, including diet and renal function.

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Urine specific gravity 1.014. Urine-specific gravity reflects the concentration of solutes in urine and the kidney's ability to concentrate or dilute urine. While changes in urine specific gravity can indicate dehydration or overhydration, it is not a direct indicator of infection. An infection is better detected through changes in WBC count and other clinical signs.

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Place a urine collection device on the infant until the specimen is obtained. This choice is not appropriate for collecting a stool specimen. A urine collection device is used for collecting urine, not stool. The specimen for ova and parasites needs to be taken directly from the rectum or diaper to accurately identify any infestations.

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Transfer the specimen to the collection container using povidone-iodine-soaked gauze. While povidone-iodine is an antiseptic, it is not typically used to transfer stool specimens. Using a sterile swab or a clean, dry container is more suitable for collecting and transporting stool samples to the lab.

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Maintain the specimen at room temperature after collection until it is transferred to the lab. Stool specimens for ova and parasites usually require refrigeration to prevent the degradation and growth of potential pathogens. Room temperature might lead to the overgrowth of bacteria and parasites, affecting the accuracy of test results.

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Decrease daily oral fluid intake. Rationale: This choice is not appropriate for a client experiencing a vaso-occlusive crisis in sickle cell anemia. In this crisis, there is a risk of dehydration due to increased fluid loss, and decreasing oral fluid intake would exacerbate this issue. Adequate hydration is important to prevent further sickling of red blood cells and maintain organ perfusion.

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Apply cold compresses to painful joints. Rationale: Applying cold compresses is not a recommended intervention for vaso-occlusive crisis in sickle cell anemia. Cold can exacerbate vasoconstriction and further compromise blood flow to the affected tissues. Warm compresses or warm baths might be more appropriate to promote vasodilation and alleviate pain.

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Administer meperidine to eliminate a fever. Rationale: Administering meperidine solely to eliminate a fever is not the primary focus of care for a vaso-occlusive crisis. The priority is to manage pain and improve tissue perfusion. Meperidine is an opioid analgesic that can be used to manage severe pain associated with sickle cell crises, but it should be given with caution due to the risk of respiratory depression and the potential for addiction.

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Gently lift the traction weights off the floor when repositioning the client. Rationale: This choice is not recommended in the care of a client in skeletal traction. Traction weights should never be lifted off the floor as they provide the necessary counter traction to align and immobilize the fractured bone. Lifting the weights could disrupt the traction and jeopardize the healing process.

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Reduce intake of foods containing fiber while nonambulatory. Rationale: While constipation can be a concern for clients in skeletal traction due to decreased mobility, reducing fiber intake is not the appropriate intervention. Adequate fiber intake is important to promote regular bowel movements and prevent constipation. Hydration and mobility exercises are more suitable approaches to manage constipation.

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Perform passive range-of-motion exercises to the affected extremity every 2 hours. Rationale: Passive range-of-motion exercises are important to maintain joint mobility and prevent muscle atrophy in a nonambulatory client. However, performing these exercises every 2 hours might be excessive and could cause unnecessary discomfort for the client. Range-of-motion exercises are usually done every 4 to 8 hours to strike a balance between maintaining joint health and providing rest.

Several small bruises on the shins are not a sign of child maltreatment. They are common in toddlers who are learning to walk and explore their environment.Bruises that are suspicious for abuse are usually located on the face, head, neck, chest, abdomen, or buttocks1.

A fracture of the arm from a bicycle injury is not a sign of child maltreatment. It is a common accidental injury in children who are active and adventurous.Fractures that are suspicious for abuse are usually spiral, metaphyseal, or rib fractures, or multiple fractures in different stages of healing1.

Biting other children while at daycare is not a sign of child maltreatment. It is a normal behavior in toddlers who are developing their social and communication skills. Biting may occur when a child is frustrated, angry, bored, or hungry.It can be prevented by providing adequate supervision, redirection, and positive reinforcement

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Encouraging active range of motion of the extremity is not recommended during the first 12 to 24 hours after a sprained wrist. Early movement can potentially worsen the swelling and delay the healing process.

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Applying warm compresses to the extremity is not the best choice to minimize swelling in the initial 12 to 24 hours after a sprained wrist. Heat can actually increase blood flow and promote more swelling in the injured area.

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Wrapping the extremity loosely with an elastic bandage might be beneficial for providing support, but it's not the primary intervention for minimizing swelling in the first 12 to 24 hours after a sprained wrist. Elevation is more effective for reducing swelling during this initial period.