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 C
Explanation
Choice A reason: Percussion precedes palpation to assess abdominal resonance and organ size without altering bowel motility. Performing it last risks inaccurate findings, as palpation may stimulate peristalsis, changing resonance patterns. This sequence ensures reliable detection of abnormalities like organomegaly or fluid accumulation in the abdomen.
Choice B reason: Auscultation is done before palpation to capture natural bowel sounds. Manipulation during palpation can alter peristalsis, affecting auscultatory findings. Early auscultation ensures accurate detection of hypoactive or hyperactive bowel sounds, critical for diagnosing conditions like ileus or obstruction in abdominal assessments.
Choice C reason: Palpation is the final step, following inspection, auscultation, and percussion, to assess for tenderness or masses. This sequence prevents manipulation from altering earlier findings, ensuring accurate identification of abdominal abnormalities like peritonitis or organ enlargement, critical for a comprehensive physical examination.
Choice D reason: Inspection is the first step, providing a visual baseline of abdominal appearance, such as distension or scars. Performing it last misses initial cues guiding subsequent steps. Early inspection ensures no manipulation affects visual assessment, vital for identifying external signs of underlying abdominal pathology.
Correct Answer is B
Explanation
Choice A reason: Performing postural drainage immediately after meals risks aspiration and discomfort due to gastric contents shifting during positioning. It should be done 1-2 hours after meals to ensure safety and efficacy in clearing mucus from the lungs, making this timing inappropriate for cystic fibrosis management.
Choice B reason: Performing postural drainage twice daily is recommended for cystic fibrosis to mobilize thick mucus from the lungs, improving airway clearance and reducing infection risk. This frequency balances effectiveness with patient tolerance, aligning with evidence-based guidelines for managing chronic respiratory conditions, making it the correct action.
Choice C reason: Using a percussion vest is an alternative to manual postural drainage but is not specified as the only method. Manual techniques are effective and standard unless a vest is prescribed. This choice assumes equipment availability, which may not apply, making it less universally appropriate than scheduled manual drainage.
Choice D reason: Positioning the child flat during postural drainage is incorrect, as specific angled positions (e.g., head-down) are needed to target lung segments and promote mucus drainage by gravity. Flat positioning reduces effectiveness and may not clear airways adequately, making this an inappropriate technique for cystic fibrosis.
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