A nurse on a pediatric unit is preparing to insert an IV catheter for a 7-year-old child who is dehydrated. Which of the following actions should the nurse take?
Use a mummy restraint to hold the child during the catheter insertion.
Perform the procedure in the child's room.
Require the parents to leave the room during the procedure.
Tell the child there will be discomfort during the catheter insertion.
The Correct Answer is B
Rationale:
A. Use a mummy restraint to hold the child during the catheter insertion: Physical restraints should be used only as a last resort, as they can increase anxiety and trauma. Non-pharmacologic methods and parental support are preferred for safely holding a child during procedures.
B. Perform the procedure in the child's room: Conducting the IV insertion in the child’s room helps reduce stress by providing a familiar environment. It also allows parental presence, which can comfort the child and improve cooperation.
C. Require the parents to leave the room during the procedure: Removing parents can increase the child’s anxiety and reduce emotional support. Parental presence is generally encouraged to help the child feel safe during invasive procedures.
D. Tell the child there will be discomfort during the catheter insertion: The nurse should provide age-appropriate explanations using simple, honest language, focusing on sensations rather than labeling it as painful, to reduce fear and encourage cooperation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Administer calcium gluconate: Calcium gluconate is the antidote for magnesium sulfate toxicity, but it should be given after stopping the infusion and assessing the client’s respiratory status. Immediate discontinuation takes priority.
B. Discontinue the infusion: Difficulty breathing indicates a potential magnesium sulfate toxicity or respiratory depression, which is a life-threatening emergency. The first action is to stop the infusion to prevent further accumulation.
C. Assess the fetal heart rate: Monitoring the fetus is important, but maternal safety takes priority over fetal assessment in a potential toxic reaction. Stabilizing the mother comes first.
D. Obtain the client's magnesium level: Lab assessment is useful for confirming toxicity, but it should not delay immediate intervention. Stopping the infusion takes precedence over obtaining levels.
Correct Answer is B
Explanation
Rationale:
A. "I will hang a pastel-colored mobile 24 inches above my baby's crib.": Newborns can only see objects clearly 8–12 inches away and are more attracted to bold patterns and contrasting colors. A mobile 24 inches away would be too far for visual stimulation.
B. "I will place a ticking clock nearby to soothe my baby throughout the day.": Rhythmic sounds, such as a ticking clock, can mimic the intrauterine environment and help calm newborns. This is an appropriate soothing technique for a 1-week-old.
C. "I will avoid picking up my baby too often to keep from spoiling him.": Holding and responding promptly to a newborn’s needs promotes bonding, emotional security, and healthy development. At this age, infants cannot be spoiled.
D. "I can use a firm pillow to prop up the bottle when feeding my baby.": Propping bottles increases the risk of choking, aspiration, and otitis media. Infants should always be held during feedings for safety and bonding.
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