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 D
Explanation
The correct answer is choice D, wooden building blocks.
Choice A rationale:
Colored paper and safety scissors are not appropriate for an 18-month-old child due to safety concerns. At this age, children are still developing fine motor skills and coordination, and the use of scissors, even safety ones, poses a risk of injury.
Choice B rationale:
Stringing beads is not suitable for an 18-month-old child as it requires more advanced fine motor skills and could pose a choking hazard. Children at this age are still prone to exploring objects by putting them in their mouths.
Choice C rationale:
Alphabet flash cards are not the best choice for an 18-month-old child with pneumonia. While flash cards can be educational, they are more suited for older children who are beginning to learn letters and words. At 18 months, play should focus on sensory and motor skill development rather than academic learning.
Choice D rationale:
Wooden building blocks are the most appropriate choice for an 18-month-old child. They encourage play that is developmentally supportive, promoting fine motor skills and creativity. Blocks can be easily handled by small hands, and there is no risk of injury or choking. Additionally, building and knocking down block towers can provide a sense of accomplishment and enjoyment for the child.
Correct Answer is B
Explanation
The correct answer is choiceb. Perceives death as a punishment.
Choice A rationale:
Preschool-aged children generally do not understand that death is permanent.They often view death as temporary or reversible, similar to what they see in cartoons.
Choice B rationale:
Preschoolers may perceive death as a punishment for something they did or thought.This age group often feels guilt and shame, believing their actions or thoughts caused the illness or death.
Choice C rationale:
Worrying about physical body changes is more typical in older children who have a better understanding of the physical aspects of illness and death.
Choice D rationale:
Feelings of isolation are more common in older children and adolescents who are more aware of social dynamics and the implications of their illness.
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