Pre-Test 1 and 2: Introduction to Special Questions Based on Official NCLEX-RN[®]
70. A nurse prepares to discontinue the IV of a child with a low platelet count. Special precautions taken by the nurse when performing this nursing action should include:
. Applying a sterile pressure dressing to the IV site.
. Applying direct pressure to the IV site for 5 minutes.
. Sending the tip of the IV catheter to the laboratory for a culture.
. Restraining the child from moving the arm with the IV site for a period of 1 hour.
Test-Taking Tip
Remember that a decreased platelet count will cause bleeding tendencies.
Content Area: Child Health, Hematological; Integrated Process: Nursing Process, Implementation; Cognitive Level: Application; Client Need/Subneed: Physiological Integrity/Reduction of Risk Potential/Potential for Complications of Diagnostic Tests/Treatments/Procedures
Pre-Test 1 and 2: Introduction to Special Questions Based on Official NCLEX-RN[®]
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Answer 1 is incorrect because a sterile pressure dressing is not necessary for the IV site. It would also be unnecessarily restrictive for the child. Answer 2 is correct because a child with a low platelet count will have bleeding tendencies. When discontinuing the IV, the nurse should treat the IV site as an arterial puncture and apply direct pressure to the site for a minimum of 5 minutes. Answer 3 is incorrect because sending the tip of the IV catheter to the laboratory for a culture would only be necessary when sepsis around the IV catheter is suspected. It would also be unnecessarily expensive and would not help the child's bleeding tendencies. Answer 4 is incorrect because it would be unnecessarily restrictive for the child and would not help the child's bleeding tendencies.