Nursing Elites

1. An infant with short bowel syndrome will be on total parenteral nutrition (TPN) for an extended period of time. What should the nurse monitor the infant for?

• A. Central venous catheter infection, electrolyte losses, and hyperglycemia
• B. Hypoglycemia, catheter migration, and weight gain
• C. Venous thrombosis, hyperlipidemia, and constipation
• D. Catheter damage, red currant jelly stools, and hypoglycemia

Correct answer: A

Rationale: Infants with short bowel syndrome requiring prolonged total parenteral nutrition (TPN) are susceptible to central venous catheter infections, electrolyte losses, and hyperglycemia. Monitoring for these complications is crucial to prevent serious outcomes. Choices B, C, and D are incorrect because they do not reflect the common complications associated with prolonged TPN in infants.

2. The mother of a child with cognitive impairment calls the nurse because her son has been gagging and drooling all morning. The nurse suspects foreign body ingestion. What physiologic occurrence is most likely responsible for the presenting signs?

• A. Gastrointestinal perforation may have occurred.
• B. The object may have been aspirated.
• C. The object may be lodged in the esophagus.
• D. The object may be embedded in the stomach wall.

Correct answer: C

Rationale: The symptoms of gagging and drooling suggest that the foreign object is likely lodged in the esophagus. This can cause significant discomfort and potential complications, requiring immediate medical evaluation.

3. What is the most common cause of bronchiolitis in infants?

• A. Adenovirus
• B. Influenza virus
• C. Respiratory syncytial virus
• D. Parainfluenza virus

Correct answer: C

Rationale: The correct answer is C, Respiratory syncytial virus (RSV). RSV is the leading cause of bronchiolitis, a common respiratory condition in infants that results in inflammation of the small airways in the lung. It is highly contagious and can cause severe respiratory distress in young children, particularly those under 2 years old. Choice A, Adenovirus, is not the most common cause of bronchiolitis in infants. Choice B, Influenza virus, may cause respiratory infections but is not the primary cause of bronchiolitis. Choice D, Parainfluenza virus, can cause croup and other upper respiratory infections but is not the main cause of bronchiolitis in infants.

4. The nurse is caring for a very low-birth-weight (VLBW) infant with a peripheral intravenous infusion. What nursing considerations regarding infiltration should be included in planning IV care?

• A. Infiltration is not solely related to the activity level of VLBW infants.
• B. Continuous infusion pumps do not always stop automatically when infiltration occurs.
• C. Hypertonic solutions can cause severe tissue damage if infiltration occurs.
• D. The infusion site should be checked regularly to prevent infiltration-related complications.

Correct answer: C

Rationale: Hypertonic solutions can damage tissues if they leak from the vein due to infiltration. It is crucial to monitor for this complication to prevent severe tissue damage. Infiltration is not solely related to the activity level of VLBW infants; it can occur due to various reasons such as vein condition, catheter placement, and fluid type. Continuous infusion pumps may not always detect infiltration, as they typically alarm for pressure changes but not all infiltration instances. Checking the infusion site regularly, preferably hourly, is essential to prevent complications like tissue damage from extravasations, fluid overload, and dehydration.

5. When caring for a child with an intravenous (IV) infusion, what is an appropriate nursing action?

• A. Change the insertion site every 24 hours.
• B. Check the insertion site frequently for signs of infiltration.
• C. Use a macrodropper to facilitate reaching the prescribed flow rate.
• D. Avoid restraining the child to prevent undue emotional stress.

Correct answer: B

Rationale: Frequent monitoring of the IV site for signs of infiltration is crucial to prevent tissue damage, especially in pediatric patients. Changing the site every 24 hours is unnecessary unless complications arise, and using a macrodropper is not specific to pediatric care.

Similar Questions