A nurse is preparing to perform a heel stick on an infant. Which of the following actions should the nurse plan to take to reduce the infant's pain during the procedure?

Apply a cool cloth to the infant's heel 5 min prior to the procedure.

Promote skin-to-skin contact with the infant's guardian during the procedure.

Provide the infant with a bottle of water during the procedure.

Apply lidocaine/prilocaine cream 15 min prior to the procedure.

Answer and Explanation

The Correct Answer is B

A. Apply a cool cloth to the infant's heel 5 min prior to the procedure: Cooling the skin can cause vasoconstriction, making the heel stick more difficult and potentially increasing discomfort. This intervention does not support pain reduction and may prolong the procedure, which can further distress the infant.

B. Promote skin-to-skin contact with the infant's guardian during the procedure: Skin-to-skin contact is an evidence-based method that reduces procedural pain in infants by stabilizing heart rate, enhancing comfort, and lowering stress responses. It offers both analgesic and calming effects, making it an effective strategy during heel sticks.

C. Provide the infant with a bottle of water during the procedure: Water does not provide analgesic benefit to infants and does not activate soothing mechanisms such as the sucrose-induced endorphin release used for pain relief. Offering plain water may also be inappropriate for young infants due to risk of water intoxication.

D. Apply lidocaine/prilocaine cream 15 min prior to the procedure: This topical anesthetic requires significantly longer, typically 30 to 60 minutes, to achieve adequate analgesic effect. Applying it only 15 minutes before the heel stick would not provide sufficient pain control, limiting its effectiveness.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is D

Explanation

A. Administer methylphenidate daily: Stimulant medications like methylphenidate are not appropriate for anorexia nervosa treatment, as they can suppress appetite and worsen weight loss. They are contraindicated in clients with this disorder.

B. Weigh the client twice a week: Weighing twice a week is insufficient for clients with anorexia nervosa. Daily, same-time, same-clothing weights are recommended to monitor progress and detect potential medical complications associated with malnutrition.

C. Focus conversations around food at mealtimes: Focusing on food can increase anxiety and reinforce preoccupations with eating. Instead, conversations should be neutral or supportive, promoting a calm and therapeutic mealtime environment.

D. Inform the client of the specific duration of meals: Setting clear expectations for meal duration helps reduce anxiety, provides structure, and supports adherence to nutritional rehabilitation. It is an effective intervention in the care plan for clients with anorexia nervosa.

A. A client who has an open fracture of the tibia and reports pain as 5 on a scale of 0 to 10 B. A client who has suspected appendicitis and reports severe lower right abdominal pain C. A client who has a penetrating head wound and fixed pupils D. A client who has flail chest and a respiratory rate of 32/min

Correct Answer is D

Explanation

A. A client who has an open fracture of the tibia and reports pain as 5 on a scale of 0 to 10: While the open fracture requires prompt attention to prevent infection and manage pain, it is not immediately life-threatening. This client can be treated after more critical, unstable patients.

B. A client who has suspected appendicitis and reports severe lower right abdominal pain: Suspected appendicitis is urgent but not immediately life-threatening unless complications like rupture occur. This client’s condition is lower priority compared to airway or breathing compromise.

C. A client who has a penetrating head wound and fixed pupils: Fixed pupils suggest a non-survivable brain injury. In a mass casualty or disaster triage situation, this client is considered expectant and would not receive immediate intervention.

D. A client who has flail chest and a respiratory rate of 32/min: Flail chest with increased respiratory rate indicates respiratory compromise and potential hypoxia, which is life-threatening. Airway and breathing take priority, so this client requires immediate intervention to stabilize breathing and prevent rapid deterioration.

View Question and Answer

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

A nurse is preparing to perform a heel stick on an infant. Which of the following actions should the nurse plan to take to reduce the infant's pain during the procedure?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is planning care for a client who is being admitted for treatment of anorexia nervosa. Which of the following interventions should the nurse include?

Correct Answer is D

Explanation

A nurse in an emergency department is triaging clients following an external natural disaster. Which of the following clients should the nurse identify to receive care first?

Correct Answer is D

Explanation

A nurse is reviewing a community health report card. Which of the following findings should the nurse expect to find in the report card?

A nurse is preparing a staff training on fall prevention for clients who have moderate dementia. Which of the following strategies should the nurse include?

A nurse on a mental health unit is caring for a client. Complete the following sentence by using the lists of options. The client is at risk for _____ as evidenced by the client's _____ .

A nurse is documenting assessment findings for a client. Which of the following is an example of subjective data?

A nurse is providing discharge teaching to a client who is taking warfarin. Which of the following information should the nurse include in the teaching?

A nurse is teaching a client about serum prealbumin. Which of the following statements should the nurse include?

The nurse continues to care for the client. For each assessment finding, click to specify if the finding is consistent with psychosis or mania. Each finding may support more than one diagnosis.

The nurse is continuing to care for the client. The nurse is providing teaching about lithium to the client and the client's adult child. Select the 3 statements the nurse should include.