A nurse is preparing to collect a blood specimen from a preschooler. Which of the following actions should the nurse take?
Give the child a pacifier that has been dipped in an oral sucrose solution during the procedure.
Apply a eutectic mixture of local anesthetics cream to the intended puncture site 1 hr before the procedure.
Instruct the parent how to perform kangaroo care during the procedure.
Administer aspirin to the child 1 hr before the procedure.
The Correct Answer is A
Choice A reason:
Using a pacifier dipped in an oral sucrose solution can help provide comfort and alleviate pain during the procedure, making it a suitable option for blood specimen collection in preschoolers.
Choice B reason:
Applying a eutectic mixture of local anesthetics cream may not be the most appropriate option for blood specimen collection in preschoolers, as it may not provide sufficient pain relief for the procedure.
Choice C reason:
Kangaroo care involves skin-to-skin contact between an infant and a parent, which is beneficial for bonding and comfort but may not be directly applicable to a blood specimen collection procedure.
Choice D reason:
Placing the infant in a prone position for sleeping is not related to blood specimen collection and may not be appropriate immediately postoperatively.
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Related Questions
Correct Answer is B
Explanation
A: Suctioning the client's airway every 2 hours is not indicated based on the provided information. The adolescent does not have a condition that compromises airway clearance, and routine suctioning can cause trauma or stimulate a vagal response, potentially leading to bradycardia.
B: Maintaining the client's head of the bed at 30° is appropriate for reducing intracranial pressure and facilitating venous drainage. The patient's symptoms of nuchal rigidity and severe headache suggest increased intracranial pressure, possibly due to meningitis, which is supported by the diagnostic results.
C: Keeping the client's room well lit is not advisable as the patient reports photophobia, which is a sensitivity to light. A well-lit room could exacerbate discomfort and pain.
D: Checking the client's temperature every 8 hours is important but not the priority intervention. The patient's condition requires more frequent monitoring due to the positive blood culture and sensitivity, indicating an active infection. More frequent temperature checks would be warranted.
Correct Answer is D
Explanation
Choice A reason:
A temperature of 37.7° C (99.9° F) is slightly elevated but not a cause for immediate concern after immunization. It can be a normal response.
Choice B reason:
Redness at the injection site is a common and expected reaction after immunization. It does not require immediate intervention.
Choice C reason:
Prolonged crying can occur after immunization, but it is not a priority over a potential allergic reaction indicated by hives.
Choice D reason:
Hives on the child's neck indicate a potential allergic reaction to the immunization. This is a priority finding and requires immediate attention from the nurse.
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