A nurse is caring for a school-age child who has a new prescription for continuous pulse oximetry monitoring. Which of the following actions should the nurse take?
Warm the skin prior to probe placement.
Reposition the probe every 2 hr.
Tape the wire to the palm of the hand.
Apply the sensor to the index fingernail.
The Correct Answer is B
Answer: B. Reposition the probe every 2 hours.
Rationale:
- A. Warm the skin prior to probe placement: While cold fingers can lead to inaccurate readings, warming the skin is not an essential step and is not routinely recommended in clinical practice.
- B. Reposition the probe every 2 hours: This is correct. Continuous pressure from the probe in one spot can cause skin breakdown and pressure injuries. Repositioning the probe every 2 hours helps to prevent this and ensure accurate readings.
- C. Tape the wire to the palm of the hand: 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.
- D. Apply the sensor to the index fingernail: 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.
Therefore, the most important action for the nurse to take is to reposition the probe every 2 hours to prevent skin breakdown and ensure accurate readings.
Additional Points:
- The nurse should also choose a clean and dry site for probe placement.
- The probe should be snug but not too tight.
- The nurse should monitor the child for signs of skin breakdown, such as redness, swelling, or pain.
- If the child is restless or active, the nurse may need to secure the probe with additional tape or a special wrap.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
After a tonic-clonic seizure, it's common for the person to inadvertently bite their tongue, cheeks, or lips during the convulsive movements. Checking the mouth for any signs of bleeding or injuries is essential to ensure the person's safety and provide appropriate care.
Choice B rationale:
Placing the child's head in a hyperextended position is not recommended after a seizure. In fact, it's important to keep the person's head and neck in a neutral position to prevent potential injury. Hyperextending the neck could lead to strain or other complications.
Choice C rationale:
Giving the child a drink of water immediately after a seizure is not necessary and might be unsafe. The child may still be disoriented or have difficulty swallowing immediately after the seizure. It's best to ensure the child's safety and monitor their condition before offering any fluids.
Choice D rationale:
Administering naloxone intramuscularly is not indicated for a tonic-clonic seizure. Naloxone is an opioid antagonist used to reverse the effects of opioid overdose. Seizures have a different underlying cause, and administering naloxone would not be effective or appropriate in this context.
Correct Answer is D
Explanation
Answer: d. Apply suction in 3 to 4-second increments.
Rationale:
- a. Instill 2 mL of 0.9% sodium chloride prior to suctioning: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.
- b. Select a catheter that fits snugly into the tracheostomy tube: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.
Opens in a new window
www.researchgate.net
Tracheostomy tube and different catheter sizes
- c. Use a clean technique when performing suctioning: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.
- d. Apply suction in 3 to 4-second increments:This is thecorrectapproach for suctioning an infant with a tracheostomy.Applying short,intermittent suction bursts minimizes the risk of hypoxia and tissue trauma while effectively removing secretions.
Therefore, the most important action for the nurse to take is to apply suction in short, 3-4 second bursts to effectively clear the mucus occlusion while minimizing risks to the infant.
Additional Points:
- The nurse should use sterile suction equipment and sterile technique throughout the procedure.
- The suction pressure should be set at the lowest effective level,typically 80-120 mmHg.
- The nurse should monitor the infant for signs of respiratory distress,such as increased work of breathing,retractions,and oxygen desaturation,before,during,and after suctioning.
- If the mucus occlusion is not cleared after several attempts,the nurse should seek assistance from ahealthcareprovider.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today