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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Limiting potassium intake is dangerous with digoxin, as low potassium (hypokalemia) increases the risk of digoxin toxicity by enhancing drug binding to cardiac cells. Adequate potassium levels are critical for safe use, as digoxin affects cardiac contractility, making this instruction incorrect and potentially harmful.
Choice B reason: Repeating a digoxin dose if the child vomits within 1 hour is unsafe without medical consultation, as it risks overdose. Digoxin has a narrow therapeutic index, and toxicity can cause arrhythmias. Parents should contact the provider for guidance, making this instruction incorrect and dangerous.
Choice C reason: Adding digoxin to juice risks inaccurate dosing, as the child may not consume the full amount, leading to underdosing or toxicity if additional doses are given. Precise administration (e.g., via syringe) ensures correct dosing, critical for digoxin’s narrow therapeutic range, making this instruction inappropriate.
Choice D reason: Having the child drink water after digoxin ensures the dose is fully swallowed, preventing loss from spitting or incomplete ingestion. This supports accurate dosing, essential for digoxin’s safe use in heart failure, where it enhances cardiac output. This instruction is safe and effective, making it correct.
Correct Answer is C
Explanation
Choice A reason: Applying testosterone gel to the genital region is contraindicated, as it increases irritation and absorption variability. It should be applied to clean, dry skin on the shoulders, upper arms, or abdomen to ensure safety and efficacy, making this action incorrect and unsafe.
Choice B reason: Checking testosterone levels in 1 week is premature, as steady-state levels typically require 2-4 weeks to stabilize. Monitoring too early may yield inaccurate results, leading to improper dose adjustments. This timing is not standard, making it an incorrect instruction.
Choice C reason: Advising the client to wait 1 hour before showering or swimming ensures adequate absorption of testosterone gel through the skin. Premature water exposure can wash off the gel, reducing efficacy. This aligns with manufacturer guidelines, making it the correct action.
Choice D reason: Applying testosterone gel every other day is incorrect, as daily application maintains consistent hormone levels for hypogonadism treatment. Alternate-day dosing disrupts therapeutic levels, reducing effectiveness. Daily use is standard, making this instruction inappropriate for proper administration.
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