A nurse is preparing to insert a peripheral intravenous line on an infant. Which of the following actions should the nurse plan to take?

Use gauze to cover the IV insertion site.

Monitor the IV site every 8 hours.

Insert the catheter into the foot.

Obtain a 24-gauge catheter.

Answer and Explanation

The Correct Answer is D

Choice A reason: Using gauze to cover an infant’s IV site obscures visualization, delaying detection of infiltration or infection. Transparent dressings are preferred, as infants’ small veins are prone to complications. Gauze increases risk by hiding signs like swelling, critical for early intervention in pediatric IV management.
Choice B reason: Monitoring an IV site every 8 hours is inadequate for infants, who need hourly checks due to small vein fragility and high infiltration risk. Frequent assessment detects complications like phlebitis or extravasation early, ensuring vascular integrity and preventing tissue damage in pediatric patients.
Choice C reason: Inserting an IV in the foot is less preferred, as scalp or hand veins are more accessible and stable in infants. Foot IVs risk dislodgement from movement and may impair circulation, increasing complications like tissue damage, making this a suboptimal choice for IV placement.
Choice D reason: A 24-gauge catheter is ideal for infants, as their small veins require smaller needles to minimize trauma and infiltration. This size ensures adequate fluid or medication delivery while reducing vascular damage, aligning with pediatric IV guidelines for safe and effective venous access.

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Correct Answer is C

Explanation

Choice A reason: Experiencing delusions can contribute to agitation, but it is not the strongest predictor of violence. Delusions may lead to unpredictable behavior, but past actions are more reliable indicators, so this factor is less definitive, making it incorrect.
Choice B reason: A history of being in prison indicates past legal issues but not necessarily violent behavior. Incarceration alone is not a direct predictor of future violence, so this factor is less reliable than actual violent history, making it incorrect.
Choice C reason: A history of violent behavior is the best predictor of future violence, as past actions strongly correlate with recurrence, per evidence-based risk assessments. This reliable indicator guides safety planning, making it the correct factor to emphasize in teaching.
Choice D reason: Substance use disorder increases impulsivity and aggression risk, but it is less predictive than a documented history of violence. Substance use is a contributing factor, not the strongest indicator, so this is incorrect compared to past behavior.

A. Remove the thermometer from the client’s room for use on another client. B. Wear a gown when providing care. C. Wash hands with an alcohol-based cleaner. D. Wear an N95 respirator when in the room.

Correct Answer is B

Explanation

Choice A reason: Removing a thermometer for use on another client risks cross-contamination, as C. difficile spores are highly transmissible. Dedicated equipment is required to prevent spread, so this action is incorrect and violates infection control protocols.
Choice B reason: Wearing a gown during care prevents C. difficile spore transmission via contact, a key precaution for this infection. This aligns with CDC contact isolation guidelines, protecting staff and other patients, making it the correct action.
Choice C reason: Washing hands with alcohol-based cleaner is ineffective against C. difficile spores, which require soap and water to physically remove them. This action is incorrect and inadequate for infection control in this scenario.
Choice D reason: Wearing an N95 respirator is unnecessary, as C. difficile is not airborne. Contact precautions (gown, gloves) suffice, so this action is incorrect and overprotective, wasting resources without addressing the transmission mode.

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A nurse is preparing to insert a peripheral intravenous line on an infant. Which of the following actions should the nurse plan to take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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