A nurse is caring for a group of clients.
Which of the following findings should the nurse report to the provider?

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.

The correct answer is choiced. Encourage the adolescent to perform incentive spirometry to maintain lung capacity.

Choice A rationale: Avoiding influenza and pneumococcal vaccines for 24 months is not recommended. Vaccinations are crucial for preventing respiratory infections, which can be particularly dangerous for individuals with muscular dystrophy due to their compromised respiratory function.

Choice B rationale: Initiating a referral for chest physiotherapy every 4 hours is excessive and impractical. While chest physiotherapy can be beneficial, it is typically recommended at a frequency that is manageable and tailored to the individual’s needs.

Choice C rationale: Recommending the adolescent use a wheelchair to prevent stress on the lower extremities is not ideal. Encouraging mobility and physical activity as tolerated is important to maintain muscle strength and function for as long as possible.

Choice D rationale: Encouraging the adolescent to perform incentive spirometry to maintain lung capacity is appropriate. Incentive spirometry helps improve lung function and prevent respiratory complications, which are common in individuals with muscular dystrophy.