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: Reassuring the sister while attending to the child and involving her in interventions reduces her anxiety, stabilizing the 5-year-old’s emotional state. This aligns with pediatric emergency care principles, making it the best initial action to manage the escalating anxiety in the emergency room.
Choice B reason: Asking the sister to leave may increase her distress and isolate the child, worsening his anxiety. Reassuring and involving her is more supportive, making this counterproductive and incorrect compared to the nurse’s role in calming both the caregiver and child effectively.
Choice C reason: Reassuring the child about his sister’s nerves doesn’t address her anxiety, which is escalating his distress. Involving the sister in care reduces both anxieties, making this insufficient and incorrect compared to the nurse’s priority of stabilizing the emotional environment in the ER.
Choice D reason: Asking the sister to calm down may heighten her distress, as she’s already hysterical, and doesn’t offer support. Reassuring and involving her helps both, making this ineffective and incorrect compared to the nurse’s action to reduce anxiety for the child and caregiver.
Correct Answer is C
Explanation
Choice A reason: Interesting textures may intrigue older infants but can overwhelm new eaters, risking rejection. Bland foods are better tolerated initially, making this less suitable and incorrect compared to the nurse’s focus on foods infants accept best when introducing solids in the class.
Choice B reason: Well-heated foods risk burns and aren’t preferred by infants, who tolerate room-temperature or slightly warm foods. Bland flavors are more acceptable, making this incorrect, as it doesn’t address the taste preference infants respond to best when starting solid foods in the diet.
Choice C reason: Bland foods are gentle on infants’ sensitive palates, encouraging acceptance when introducing solids. This aligns with pediatric nutrition guidelines for transitioning diets, making it the correct factor for the nurse to highlight in teaching parents about starting solid foods for infants.
Choice D reason: Thickened foods may pose choking risks or be hard to swallow for new eaters. Bland foods are more readily accepted, making this incorrect, as it doesn’t prioritize the flavor profile infants respond to best when introducing solid foods in the parent education class.
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