When initiating a peripheral intravenous (IV) infusion on an infant, what action should the nurse take?
Apply soft restraints to all four extremities.
Assess the dorsal surface of the feet for an IV site.
Instruct parents to sing or croon to the infant.
Select a site that is least restrictive to the infant.
The Correct Answer is D
Choice A rationale
Applying soft restraints to all four extremities of an infant is not typically recommended when initiating a peripheral intravenous (IV) infusion. Restraints can cause distress and may not be necessary for the procedure.
Choice B rationale
While the dorsal surface of the feet can be used as an IV site, it is not typically the first choice for infants. The veins in the feet can be difficult to access and the location can be inconvenient for the infant.
Choice C rationale
Instructing parents to sing or croon to the infant can be comforting and may help soothe the infant during the procedure. However, this action alone does not directly facilitate the successful initiation of an IV infusion.
Choice D rationale
Selecting a site that is least restrictive to the infant is the most appropriate action when initiating a peripheral IV infusion. This can make the procedure less distressing for the infant and allow for easier movement after the IV is in place.
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Related Questions
Correct Answer is D
Explanation
Choice A rationale
Diaphragmatic respirations are not typically associated with acute respiratory distress in a child with respiratory syncytial virus (RSV). Diaphragmatic respirations are normal in infants and young children.
Choice B rationale
A resting respiratory rate of 35 breaths/min is within the normal range for a 1-year-old child and would not typically indicate acute respiratory distress.
Choice C rationale
Bilateral bronchial breath sounds are normal findings and would not typically indicate acute respiratory distress in a child with RSV45.
Choice D rationale
Flaring of the nares, or nostrils, can be a sign of respiratory distress in infants and young children. It indicates that the child is using additional muscles to breathe, which can occur when the lower airways are blocked or narrowed, as in a severe RSV infection.
Correct Answer is A
Explanation
Choice A rationale
The first action the nurse should take when caring for an adolescent with type 1 diabetes mellitus who presents with an HbA1c of 11% (97 mmol/mol), thirst, and blurred vision is to obtain point-of-care glucose. These symptoms are indicative of hyperglycemia, and immediate blood glucose testing is necessary to confirm this and guide further treatment.
Choice B rationale
Assessing urine for ketones is important in managing diabetes, especially in cases of suspected diabetic ketoacidosis. However, this would not be the first action to take in this scenario.
Choice C rationale
Checking blood pressure is a standard part of any physical assessment, but it would not be the first action to take in this scenario.
Choice D rationale
Reviewing prior insulin prescriptions can provide valuable information about the patient’s management of their diabetes, but it would not be the first action to take in this scenario.
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