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A nurse is caring for an 8-month-old infant who is receiving intravenous (IV) fluids via a 24-gauge catheter. Which of the following statements by the client's mother indicates that the nurse should check the site for signs of infiltration?
- A. My baby's fingers are looking swollen.
- B. The tape is coming off the IV needle.
- C. There's blood backing up my baby's IV tubing.
- D. There's a long red streak up my baby's arm.
Correct Answer: A
Rationale: Swelling around the IV site can indicate infiltration where IV fluids leak into surrounding tissues.
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A nurse is caring for a toddler who had a cast applied 2 hr ago due to multiple fractures of the right hand. Which of the following findings should the nurse report immediately to the charge nurse?
- A. The parent reports the child will not keep the arm elevated on the pillow.
- B. The fingers on the right hand have a capillary refill of 4 seconds.
- C. The fingertips of the right hand are swollen and bruised.
- D. The child is not attempting to move her right arm or fingers.
Correct Answer: B
Rationale: A capillary refill time of more than 2 seconds indicates poor perfusion which can be a sign of compartment syndrome.
A nurse is caring for a child who is experiencing an acute asthma attack. Which of the following medications should the nurse administer first?
- A. Methylprednisolone
- B. Montelukast
- C. Albuterol
- D. Fluticasone
Correct Answer: C
Rationale: Albuterol is a short-acting beta-agonist that provides rapid bronchodilation. It is the first-line medication for immediate relief of bronchospasm during an acute asthma attack.
A nurse is caring for a toddler who is scheduled to have a lumbar puncture. Which of the following actions should the nurse take?
- A. Restrain the toddler for 1 hr after the procedure.
- B. Place the toddler in a side-lying
- C. knee-chest position.
- D. Ask another nurse to assist with holding the toddler in a prone position.
- E. Swaddle the toddler in a warm blanket.
Correct Answer: B
Rationale: This position helps to open the spaces between vertebrae, facilitating the lumbar puncture.
A nurse is providing teaching about Iron deficiency anemia to the parents of a 14-month-old. Which of the following should the nurse recommend as a method of preventing iron deficiency anemia?
- A. Avoid a diet consisting of primarily milk.
- B. Include whole grains and legumes in the diet.
- C. Administer fat-soluble vitamins daily.
- D. Limit intake of high-protein foods.
Correct Answer: A
Rationale: Milk especially cow's milk is low in iron and can inhibit iron absorption. Excessive milk consumption can also lead to iron deficiency anemia by displacing iron-rich foods from the diet and potentially causing gastrointestinal bleeding in infants.
A nurse is collecting data from a 4-year-old child. Which of the following findings should the nurse expect?"
- A. Heart rate 110/min
- B. Capillary refill greater than 3 seconds
- C. Weight gain of 0.9 kg (2 lb) in a year
- D. Respiratory rate 32/min
Correct Answer: A
Rationale: A heart rate of 110 beats per minute is within the normal range for a 4-year-old child. The typical heart rate for this age is between 80 to 120 beats per minute.