Nokea
The nurse determines that a child's intravenous infusion has infiltrated. The infused solution is a vesicant. What is the most appropriate nursing action?
- A. Stop the infusion and apply ice.
- B. End the infusion and notify the practitioner.
- C. Slow the infusion rate and notify the practitioner.
- D. Discontinue the infusion and apply warm compresses.
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
You may also like to solve these questions
What amount of fluid loss occurs with moderate dehydration?
- A. <50 ml/kg
- B. 50 to 90 ml/kg
- C. <5% total body weight
- D. >15% total body weight
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
An infant with hydrocephalus is hospitalized for surgical placement of a ventriculoperitoneal shunt. Postoperative nursing care would include what?
- A. Monitor closely for signs of infection.
- B. Place the child with the operative side of the head up.
- C. Avoid pumping the shunt reservoir to maintain patency.
- D. Avoid maintaining a Trendelenburg position to decrease pressure on the shunt.
Correct Answer: A
Rationale: Postoperative nursing care for an infant with hydrocephalus who underwent ventriculoperitoneal shunt placement includes monitoring closely for signs of infection, as infection is the greatest hazard in the postoperative period. Signs of cerebrospinal fluid infection to watch for include elevated temperature, poor feeding, vomiting, decreased responsiveness, and seizure activity. The child should be placed with the operative side of the head up to reduce pressure on the valve. The shunt reservoir should not be pumped to maintain patency, as this can disrupt its function. Maintaining a Trendelenburg position to decrease pressure on the shunt is contraindicated as it can lead to increased intracranial pressure and compromise the shunt's effectiveness.
Which parental statement indicates correct understanding of information presented regarding the prevention of iron deficiency anemia in infants?
- A. "We will add green leafy vegetables to our child's low-iron formula."
- B. "We will discontinue the use of vitamin C supplements by 6 months of age."
- C. "We will begin an iron-fortified infant cereal at 4 to 6 months of age."
- D. "We will introduce cow's milk by 6 months of age."
Correct Answer: C
Rationale: The correct answer is C. Introducing iron-fortified cereal between 4 to 6 months of age is a recommended practice to prevent iron deficiency anemia in infants. Iron-fortified infant cereals are a good source of iron for infants. Choices A and B are incorrect because adding green leafy vegetables to low-iron formula and discontinuing vitamin C supplements do not directly address the prevention of iron deficiency anemia. Choice D is incorrect because cow's milk should be avoided before 12 months of age as it is low in iron and can lead to intestinal blood loss, increasing the risk of iron deficiency anemia.
The nurse is preparing a presentation on compensated, decompensated, and irreversible shock in children. What clinical manifestations related to decompensated shock should the nurse include? (Select all that apply.)
- A. All below
- B. Oliguria
- C. Confusion
- D. Pale extremities
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
A four-year-old boy is admitted to the hospital with leg pain and fever. He is pale-looking and has bruises over various areas of his body. The physician suspects acute lymphoblastic leukemia (ALL). Which test would be used to confirm the diagnosis?
- A. Bone marrow aspirate
- B. Red blood cell count
- C. Lumbar puncture
- D. Bone scan
Correct Answer: A
Rationale: A bone marrow aspirate is the definitive test to confirm acute lymphoblastic leukemia (ALL) in this case. It allows for the examination of leukemic cells in the bone marrow, providing a direct assessment of the disease. Red blood cell count (Choice B) is not specific for diagnosing leukemia but may show anemia commonly seen in leukemia patients. Lumbar puncture (Choice C) is used to assess central nervous system involvement, not primarily for confirming ALL. Bone scan (Choice D) is not a standard diagnostic test for ALL and is mainly used for evaluating bone metastases in other conditions.