Tess is a 5-year-old client who must receive an IV infusion of antibiotics. She is anxious, resistant, and wiggly. To keep her safe during the time the IV is in place, the nurse would choose which method to restrain her?
Allow her caregiver to hold her during the time the IV is in place.
Restrain her with a mummy restraint and loosen and rewrap it every 3 hours.
Use a clove-hitch restraint to keep her arm still and loosen it every 2 hours.
Restrain her on a papoose board and release her as soon as the IV is in place.
The Correct Answer is C
Choice A reason: Caregiver holding may comfort but is unreliable for keeping a wiggly 5-year-old still, risking IV dislodgement. A clove-hitch restraint ensures arm stability while allowing some movement, making this less safe and incorrect for maintaining IV security during antibiotic infusion in a resistant child.
Choice B reason: Mummy restraints are excessive for an IV, restricting the whole body and potentially distressing a 5-year-old. A clove-hitch restraint targets the arm, balancing safety and comfort, making this overly restrictive and incorrect for the specific need to secure the IV site in this scenario.
Choice C reason: A clove-hitch restraint secures the arm, preventing IV dislodgement in a resistant 5-year-old while allowing some movement. Loosening every 2 hours ensures circulation, aligning with pediatric nursing safety standards for IV therapy, making it the correct method for ensuring safety during infusion.
Choice D reason: A papoose board is used for short procedures, not prolonged IV infusions, and releasing immediately negates its purpose. A clove-hitch restraint maintains IV security over time, making this impractical and incorrect for ensuring safety during the antibiotic infusion period for the child.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Lung and spleen damage is complex and internal, making it hard for a 4-year-old to comprehend compared to visible injuries like rashes or burns. This requires more explanation, aligning with pediatric developmental understanding, making it the correct diagnosis needing the most help for comprehension.
Choice B reason: A measles rash is visible and relatable, easier for a 4-year-old to understand than internal organ damage. Lung and spleen injuries are more abstract, making this less challenging and incorrect compared to the diagnosis requiring the most explanation for the child’s understanding.
Choice C reason: Broken bones from a fall are tangible and can be explained with casts or pain, more understandable for a 4-year-old. Internal organ damage is less concrete, making this simpler and incorrect compared to the complex diagnosis needing more help for the child’s comprehension.
Choice D reason: Burns from fireworks are visible and painful, allowing a 4-year-old to grasp the injury more easily than internal organ damage. Lung and spleen issues are more abstract, making this more concrete and incorrect compared to the diagnosis requiring the most explanation for understanding.
Correct Answer is C
Explanation
Choice A reason: Placing the probe on the chest is not a standard pulse oximetry site and gives inaccurate readings. Explaining the device’s purpose addresses the caregiver’s concern, making this ineffective and incorrect compared to educating about the sensor’s role in monitoring the infant’s oxygen levels.
Choice B reason: Pulse oximetry measures oxygen saturation, not respiratory retractions, which are observed visually. Clarifying its purpose reassures the caregiver, making this inaccurate and incorrect compared to explaining the device’s function to address concerns about the sensor’s use on the infant.
Choice C reason: Explaining that pulse oximetry measures oxygen saturation clarifies its importance, reassuring the caregiver about its necessity and addressing tightness concerns. This aligns with pediatric nursing education principles, making it the prioritized response to ensure compliance with monitoring the infant’s respiratory status.
Choice D reason: Checking the probe site every 8 hours prevents skin issues but doesn’t address the caregiver’s concern about tightness. Explaining the device’s purpose promotes understanding, making this secondary and incorrect compared to educating to maintain the sensor’s use on the infant.
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