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When starting a peripheral intravenous (IV) infusion on an infant, which intervention should the nurse implement?
- A. Select a site that is least restrictive to the infant.
- B. Assess dorsal surface of feet for an IV site.
- C. Instruct parents to sing or croon to the infant.
- D. Apply soft restraints to all four extremities.
Correct Answer: A
Rationale: Selecting a least restrictive site minimizes discomfort and maintains mobility, ensuring safe and effective IV placement.
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The nurse is assessing an infant with aortic stenosis and identifies bilateral fine crackles in both lung fields. Which additional finding should the nurse expect to obtain?
- A. Hemiplegia.
- B. Fever.
- C. Vigorous feeding and satiation.
- D. Hypotension and tachycardia.
Correct Answer: D
Rationale: Aortic stenosis can lead to heart failure and pulmonary edema, causing bilateral fine crackles, with hypotension and tachycardia as additional signs of decreased cardiac output.
During her sports physical examination, 15-year-old female requests oral contraceptives. She explains that she is sexually active and does not want her parents to know. Which action should the nurse take?
- A. Encourage the client to discuss her need for contraceptives with her parents.
- B. Counsel the client about the risks and benefits of using oral contraceptives.
- C. Explain that she needs parental approval to receive contraceptives.
- D. Tell the client how to receive a variety of free oral contraceptives from the clinic.
Correct Answer: B
Rationale: Providing counseling about the risks and benefits of oral contraceptives ensures the client is informed and respects her autonomy and privacy while ensuring she receives necessary information.
A male adolescent arrives at the clinic and reports intense pain in the testicular area that occurred during football practice at high school. The nurse observes the scrotum and identifies significant erythema and swelling. Which action should the nurse take?
- A. Report the findings immediately to the healthcare provider.
- B. Obtain a swab of secretions from the penis and urethra.
- C. Collect a sterile urine sample for culture and sensitivity.
- D. Provide the adolescent with a urinal for urinary hesitancy.
Correct Answer: A
Rationale: Significant erythema and swelling suggest testicular torsion, a medical emergency requiring immediate reporting.
A child receives a prescription for loratadine 5 mg by mouth once day. The bottle is labelled 'Loratadine for Oral Suspension, USP 5 mg per 5 mL.' How many teaspoons should the nurse instruct the parent to administer with each dose?
- A. 1 teaspoon
Correct Answer: A
Rationale: 5 mg of loratadine corresponds to 5 mL (1 teaspoon) of the suspension, as per the concentration provided.
A 6-year-old boy with bronchial asthma takes the beta-adrenergic agonist agent albuterol. The child's mother tells the nurse that she uses this medication to open his son's airway when he is having trouble breathing. What is the nurse's best response?
- A. Advise the mother that overuse of the drug may cause chronic bronchitis.
- B. Assure the mother that she is using the medication correctly.
- C. Confirm that the medication helps to reduce airway inflammation.
- D. Recommend that the mother bring the child in for immediate evaluation.
Correct Answer: B
Rationale: Using albuterol to relieve acute breathing difficulties is correct, as it relaxes airway muscles.