A nurse is preparing to initiate intravenous (IV) antibiotic therapy for a newly admitted 12-month-old infant. Which of the following actions should the nurse plan to take?

Use a 24-gauge catheter to start the IV.

Start the IV in the infant's foot.

Cover the insertion site with an opaque dressing.

Change the IV site every 3 days.

Answer and Explanation

The Correct Answer is A

Choice A reason: A 24-gauge catheter is appropriate for a small and fragile vein of a 12-month-old infant. It minimizes the risk of damaging the vein and ensures the comfort of the infant during IV therapy.

Choice B reason: Starting an IV in the infant's foot is not the first choice due to the risk of movement dislodging the catheter. The hand or the antecubital fossa are preferred sites for IV insertion in infants.

Choice C reason: While it is important to cover the IV insertion site, an opaque dressing is not necessary. A transparent dressing is preferred as it allows for continuous visibility of the site for signs of infection or phlebitis.

Choice D reason: The IV site should not be routinely changed every 3 days. It should be changed based on clinical indications such as signs of infection, infiltration, or phlebitis, or if the IV becomes dislodged.

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Correct Answer is C

Explanation

Choice A reason: Weight loss is not typically an indication of heart failure. In fact, patients with heart failure may experience weight gain due to fluid retention.

Choice B reason: Decreased respirations are not a common sign of heart failure. Instead, heart failure can cause increased respiratory rate and effort due to fluid accumulation in the lungs.

Choice C reason: Exercise intolerance, or difficulty in engaging in physical activity, is a classic symptom of heart failure. It occurs due to the heart's inability to pump enough blood to meet the body's demands during exercise.

Choice D reason: Bradycardia, or a slower than normal heart rate, is not a direct indication of heart failure. While it can be associated with certain cardiac conditions, it is not a specific sign of heart failure.

A. Use a bulb syringe to suction the nares. B. Initiate IV antibiotic therapy. C. Administer a meningococcal vaccine upon admission. D. Place the infant in a room with negative-pressure airflow.

Correct Answer is A

Explanation

Choice A reason: Using a bulb syringe to suction the nares is appropriate for an infant with bronchiolitis to help clear mucus and maintain airway patency, as bronchiolitis often causes nasal congestion.

Choice B reason: Initiating IV antibiotic therapy is not typically indicated for bronchiolitis, which is usually caused by a virus, and antibiotics are ineffective against viral infections.

Choice C reason: Administering a meningococcal vaccine upon admission is not related to the immediate care needs of an infant with bronchiolitis and is not part of standard treatment for this condition.

Choice D reason: Placing the infant in a room with negative-pressure airflow is not necessary for bronchiolitis, as this measure is reserved for airborne infections like tuberculosis, not for bronchiolitis which is spread through droplets.

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