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 B
Explanation
Choice A reason: Constipation is not typically associated with nephrotic syndrome. It may be related to dietary factors, dehydration, or other gastrointestinal issues.
Choice B reason: Increased abdominal girth can be an indication of nephrotic syndrome due to the accumulation of fluid in the abdomen (ascites) as a result of low albumin levels in the blood, which is a characteristic of this condition.
Choice C reason: Irritability can be a non-specific symptom and may be caused by a variety of factors. It is not a direct indication of nephrotic syndrome.
Choice D reason: Increased urinary output is not characteristic of nephrotic syndrome. In fact, decreased urine output may be observed due to the loss of protein in the urine and subsequent fluid retention in the body.
Correct Answer is B
Explanation
Choice A reason: Applying tepid water to the old dressings can help with their removal and may reduce discomfort, but it does not address the greatest risk to the client, which is infection.
Choice B reason: Checking the wound sites for manifestations of infection is crucial as burn injuries compromise the skin's protective barrier, making the client highly susceptible to infections. Infections can lead to further complications and delay healing.
Choice C reason: Performing passive range-of-motion exercises is important for maintaining joint mobility and preventing contractures in burn patients, but it is not the primary intervention for addressing the greatest risk of infection.
Choice D reason: Adjusting the room temperature to 33°C (91.4°F) can create a more comfortable environment for the burn patient and prevent hypothermia, but it is not directly related to the prevention of infection, which is the greatest risk.
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