Nokea
Which restraint is most appropriate for the insertion of an intravenous line in a scalp vein of an infant?
- A. Mummy
- B. Clove hitch
- C. Jacket
- D. Elbow
Correct Answer: A
Rationale: A mummy restraint immobilizes the infant safely for scalp vein IV insertion.
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What should be the next action by the nurse?
- A. Give the medication after confirming the child's name from the foot of the crib.
- B. Ask the charge nurse to give the medicine.
- C. Confirm the identity with the charge nurse, make a new bracelet, and give the medicine.
- D. Delay the medication until the admissions office can supply a new ID bracelet.
Correct Answer: C
Rationale: Confirming identity with the charge nurse and making a new bracelet ensures safe medication administration.
What will the nurse expect the child's daily urinary output to be?
- A. 400 to 500 mL
- B. 500 to 600 mL
- C. 600 to 720 mL
- D. 700 to 1000 mL
Correct Answer: C
Rationale: The average daily urine output for a 4-year-old is 600 to 720 mL, reflecting normal renal function.
What should the nurse assess to determine the method of transportation for a pediatric patient?
- A. Age
- B. Race
- C. Vital signs
- D. Distance to travel
- E. Level of consciousness
Correct Answer: A,D,E
Rationale: Age, distance to travel, and level of consciousness determine safe transportation methods; race is irrelevant.
How would the nurse position the auricle when administering the ear drops?
- A. Up and back
- B. Down and back
- C. Up and out
- D. Down and out
Correct Answer: A
Rationale: For children 3 years and older, pulling the auricle up and back straightens the ear canal for effective ear drop administration.
What statement made by the adolescent led the nurse to determine she understood the instructions?
- A. I should wash my perineum with soap and water, then begin to urinate.'
- B. I clean the perineum from front to back with an antiseptic wipe before I urinate.'
- C. I'll collect the first stream of urine in a sterile container.'
- D. I will discard the first void and collect a freshly voided specimen 30 minutes later.'
Correct Answer: B
Rationale: Cleaning the perineum from front to back with an antiseptic wipe ensures a clean-catch urine specimen.