A nurse is preparing to perform a venipuncture on a 4-year-old child. Which of the following actions should the nurse take to ensure atraumatic care?
Ask the child's parent to leave the room during the procedure.
Perform the procedure in the unit's playroom.
Apply a topical anesthetic cream 1 hr prior to the procedure.
Explain the procedure in detail to the child 3 hr prior to the procedure.
The Correct Answer is C
A. Asking the child's parent to leave the room during the procedure may increase the child's anxiety and make the procedure more traumatic.
B. Performing the procedure in the unit's playroom may not provide the necessary equipment and sterile environment required for a venipuncture.
C. Applying a topical anesthetic cream helps reduce pain and discomfort during the venipuncture, promoting atraumatic care.
D. Explaining the procedure in detail to the child 3 hours prior to the procedure may increase anxiety and anticipation, making the procedure more traumatic.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","D","E","G"]
Explanation
A. Administer IV fluids intake: Hydration is a key intervention during a vaso-occlusive crisis. IV fluids help reduce blood viscosity and promote better circulation, which decreases the risk of further sickling.
B. Give oral hydroxyurea: Hydroxyurea reduces the frequency of sickling episodes by increasing fetal hemoglobin levels. It is part of long-term therapy and may be continued during acute care.
C. Administer meperidine IV for pain: Meperidine is avoided because its metabolite, normeperidine, can cause neurotoxicity and seizures. Opioids such as morphine or hydromorphone are preferred.
D. Instructing the parent to ensure the pneumococcal vaccine is current: Children with sickle cell disease are functionally asplenic and at high risk for infection. Ensuring vaccines are up to date is an important component of overall care.
E. Place the client on strict bedrest: Limiting activity helps reduce oxygen demand and pain caused by movement during a crisis. Bedrest supports recovery and comfort.
F. Apply cold compresses to the affected joints: Cold therapy causes vasoconstriction, which can worsen sickling. Warm compresses are preferred to improve blood flow and relieve pain.
G. Monitor oxygen saturation continuously: Monitoring oxygen saturation allows for early detection of hypoxia, which can trigger or exacerbate sickling episodes. Prompt intervention helps prevent complications.
Correct Answer is D
Explanation
A) Neck vein distention is not typically associated with acetylsalicylic acid poisoning.
B) Jaundice is not typically associated with acetylsalicylic acid poisoning.
C) Polyuria is not typically associated with acetylsalicylic acid poisoning.
D) Hyperpyrexia, or extremely high fever, is a common symptom of severe acetylsalicylic acid poisoning due to its effects on the central nervous system and metabolism.
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