A nurse is preparing to initiate IV antibiotic therapy for a newly admitted 12-month-old infant.
Which of the following actions should the nurse plan to take?
Cover the insertion site with an opaque dressing
Use a 24-gauge catheter to start the IV
Start the IV on the infant’s foot
Change the IV site every 3 days
The Correct Answer is B
Choice A rationale
Covering the insertion site with an opaque dressing is not typically recommended for infants. Transparent dressings are usually preferred because they allow for easy inspection of the site for signs of infection or complications.
Choice B rationale
Using a 24-gauge catheter to start the IV is the correct action. This size is appropriate for a 12-month-old infant and will cause the least amount of discomfort and trauma to the vein.
Choice C rationale
Starting the IV on the infant’s foot is not typically recommended. The hands and arms are usually preferred sites for IV insertion in infants.
Choice D rationale
Changing the IV site every 3 days is not typically necessary unless there are signs of complications such as infection or infiltration. Frequent site changes can cause unnecessary discomfort and trauma to the infant.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Question 1: The correct answer is Choice c. Perform developmental testing for delays.
Lead poisoning can lead to cognitive, behavioral, and developmental impairments, making developmental testing crucial for assessing potential delays and planning interventions. Developmental testing allows healthcare providers to identify any areas of concern early on, enabling them to implement appropriate interventions to support the child's development and mitigate the effects of lead poisoning.
Choice A rationale: Obtaining a stool specimen for lead levels is not the appropriate action in this scenario. Lead poisoning is typically assessed through blood lead levels, not stool specimens. Stool specimens are more commonly used for assessing gastrointestinal issues or infections rather than lead levels.
Choice B rationale: Initiating a low-iron diet for lead absorption is not recommended. Iron deficiency can actually increase lead absorption in the body, so reducing iron intake could potentially exacerbate the issue. Instead, ensuring an adequate intake of iron-rich foods may be beneficial for overall health but is not a primary intervention for lead poisoning.
Choice D rationale: Inspecting the skin for discoloration is not a relevant action for assessing lead poisoning. While lead poisoning can manifest in various symptoms, skin discoloration is not typically associated with lead exposure. Other signs and symptoms such as cognitive, behavioral, and developmental impairments are more indicative of lead poisoning.
Correct Answer is C
Explanation
Answer is choice C.
Choice A rationale: The rationale for Choice A involves understanding the principles of mobilization and rehabilitation following the application of an arm cast. While it is essential to limit strenuous activities involving the affected arm to prevent further injury or displacement of the fracture, completely immobilizing the fingers of the broken arm can lead to joint stiffness, muscle atrophy, and impaired circulation. Encouraging the client to move the fingers and elbow within the limits of comfort and physician instructions helps maintain joint mobility, prevent contractures, and promote blood flow, supporting the overall healing process.
Choice B rationale: Statement B pertains to the expected course of swelling following the application of an arm cast. While mild swelling is a common immediate response to trauma or immobilization, persistent or worsening swelling may indicate underlying complications such as compartment syndrome, vascular compromise, or infection. Monitoring and managing swelling are crucial aspects of post-cast care to prevent complications and ensure optimal healing outcomes. Therefore, expecting fingers to remain swollen for several days without further assessment or intervention may overlook potential issues requiring medical attention.
Choice C rationale: Elevating the broken arm on pillows at night is a fundamental aspect of post-cast care aimed at reducing swelling and promoting comfort and healing. Elevating the affected limb above the level of the heart helps enhance venous return and lymphatic drainage, thereby minimizing edema and alleviating discomfort associated with swelling. Additionally, maintaining proper elevation during periods of rest supports tissue perfusion and facilitates the resolution of inflammation, contributing to the overall recovery process. By expressing intent to elevate the arm on pillows at night, the client demonstrates comprehension of an essential self-care measure conducive to optimal healing and rehabilitation.
Choice D rationale: The statement regarding sprinkling baby powder into the cast if the arm itches reflects a misunderstanding of appropriate cast care practices. Introducing foreign substances, such as powders or objects, into the cast can create a conducive environment for bacterial growth, increase the risk of skin irritation or infection, and compromise the structural integrity of the cast. Instead of using powders, clients are advised to employ non-invasive techniques to alleviate itching, such as gently tapping or blowing cool air into the cast or seeking medical guidance for alternative solutions. Encouraging adherence to recommended cast care protocols helps minimize complications and promote favorable outcomes during the healing process.
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