The nurse needs to take a B/P on a 3 year old who is in the playroom. What is the best intervention?
Document B/P not obtained because child was in the playroom.
Take the child back to their room, take their B/P and then take them back to the playroom.
Take the child to the treatment room.
Take the B/P in the playroom.
The Correct Answer is D
A. Document B/P not obtained because the child was in the playroom.
This is not the best option. The nurse should attempt to obtain the blood pressure as part of routine monitoring.
B. Take the child back to their room, take their B/P and then take them back to the playroom.
This may disrupt the child's play and is not the most efficient approach for routine blood pressure monitoring.
C. Take the child to the treatment room.
This might be unnecessary for a routine blood pressure check and could cause unnecessary anxiety for the child.
D. Take the B/P in the playroom.
This is the best intervention. If possible, taking the blood pressure in the playroom allows the child to remain in a familiar and comfortable environment, reducing anxiety and promoting cooperation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","D"]
Explanation
A. Allow the child to hold the thermometer in their mouth until it beeps:
Allowing the child to hold the thermometer can provide a sense of control and involvement in the process. It may help reduce anxiety and make the experience less intimidating for the child. The beeping sound indicates when the temperature measurement is complete.
B. If the child protests, tell them you will come back later:
This choice is not recommended because it ignores the child's immediate needs and concerns. It may increase anxiety or fear, and delaying the process may not be in the best interest of the child's well-being.
C. Have the parents wait outside the room:
While it's common to have parents present during medical procedures for emotional support, in this case, involving the parents may not directly address the child's need for control during the temperature measurement.
D. Ask the child if it is ok to take their temperature:
Asking the child for permission respects their autonomy and involves them in the decision-making process. It promotes a sense of control and may reduce any potential resistance or fear the child might have.
Correct Answer is ["46"]
Explanation
To provide adequate hydration for a toddler with dehydration, the nurse needs to calculate the daily fluid requirements based on the child's weight and then divide it by 24 hours to get the hourly rate.
For a 12 kg toddler, the daily fluid requirement is 1000 ml for the first 10 kg plus 50 ml for each additional kg, which equals 1100 ml.
Therefore, the hourly rate is 1100 ml / 24 hours, which is about 46 ml.
The nurse would set the pump at 46 ml per hour.
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