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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: The concrete operational phase typically begins around age 7 and is characterized by the development of logical thought about concrete events. This phase is not typical for preschoolers, who are usually between the ages of 3 and 5.
Choice B reason: The formal operational phase usually starts at age 11 or older. It involves abstract thinking and the ability to systematically plan for the future, which is beyond the cognitive abilities of a preschooler.
Choice C reason: The preoperational phase occurs from ages 2 to 7. During this stage, children begin to engage in symbolic play and learn to manipulate symbols, but they do not yet understand concrete logic.
Choice D reason: The sensorimotor phase is from birth to about age 2. During this stage, infants learn about the world through their senses and actions, such as looking and touching. Preschoolers have typically moved beyond this phase.
Correct Answer is D
Explanation
Choice A reason: This is not the correct instruction to include in the discharge teaching. Perform clean intermittent catheterization every 8 hours is a possible intervention for infants who have neurogenic bladder dysfunction due to spinal cord injury or spina bifida. However, not all infants who have myelomeningocele repair require catheterization. The nurse should assess the infant’s bladder function and teach the guardian how to perform catheterization if needed.
Choice B reason: This is not the correct instruction to include in the discharge teaching. Use a rectal thermometer to stimulate the passage of stool twice per day is a possible intervention for infants who have neurogenic bowel dysfunction due to spinal cord injury or spina bifida. However, not all infants who have myelomeningocele repair require rectal stimulation. The nurse should assess the infant’s bowel function and teach the guardian how to manage constipation or fecal incontinence if needed.
Choice C reason: This is not the correct instruction to include in the discharge teaching. Anticipate gradual loss of function in the lower extremities is a possible outcome for infants who have myelomeningocele repair, depending on the location and severity of the defect. However, the nurse should not assume that the infant will lose function in the lower extremities. The nurse should monitor the infant’s motor and sensory development and provide appropriate interventions to promote mobility and prevent complications.
Choice D reason: This is the correct instruction to include in the discharge teaching. Check toys and pacifiers for the presence of latex is an important precaution for infants who have myelomeningocele repair, as they are at risk of developing latex allergy due to repeated exposure to latex products during surgery and medical procedures. The nurse should teach the guardian how to identify and avoid latex-containing items and how to recognize and treat signs of allergic reaction.
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