Nursing Elites

1. 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: If a vesicant solution infiltrates, stopping the infusion immediately and notifying the practitioner is critical to prevent tissue damage. Cold or warm compresses should only be applied following specific medical advice based on the vesicant involved.

2. A health care provider prescribes feedings of 1 to 2 oz Pedialyte every 3 hours and to advance to 1/2 strength Similac with iron as tolerated postoperatively for an infant who had a pyloromyotomy. The nurse should decide to advance the feeding if which occurs?

• A. The infant's IV line has infiltrated.
• B. The infant has not voided since surgery.
• C. The infant's mother states the infant is tolerating the feeding okay.
• D. The infant is taking the Pedialyte without vomiting or distention.

Correct answer: D

Rationale: The decision to advance feedings after a pyloromyotomy is based on the infant's ability to tolerate the current feedings without vomiting or abdominal distention. Ensuring the infant can keep down Pedialyte is the key indicator for moving to the next stage of feeding. Choices A, B, and C are incorrect because they do not directly relate to the infant's ability to tolerate the feeding. An infiltrated IV line, lack of voiding, or the mother's statement do not provide direct information on the infant's tolerance to the feeding, unlike the absence of vomiting and distention.

3. The nurse is selecting a site to begin an intravenous infusion on a 2-year-old child. The superficial veins on his hand and arm are not readily visible. What intervention should increase the visibility of these veins?

• A. Gently tap over the site.
• B. Apply a cold compress to the site.
• C. Raise the extremity above the level of the body
• D. Use a rubber band as a tourniquet for 5 minutes.

Correct answer: A

Rationale: Gently tapping over the site helps dilate the veins and increase visibility. Applying a cold compress or raising the extremity above the body level constricts the veins, making them harder to access. Prolonged tourniquet use can cause discomfort and venous congestion.

4. What condition is often associated with severe diarrhea?

• A. Metabolic acidosis
• B. Metabolic alkalosis
• C. Respiratory acidosis
• D. Respiratory alkalosis

Correct answer: A

Rationale: Severe diarrhea can lead to a loss of bicarbonate, resulting in metabolic acidosis. This is a common complication of prolonged or severe diarrhea, especially in children.

5. A new mom is instructed to have her toddler brush his teeth every night after dinner. This is an example of __________ which increases the toddler’s sense of security and self-mastery.

• A. Negativism
• B. Diversionary activity
• C. Critical play
• D. Ritualism

Correct answer: D

Rationale: The correct answer is D, Ritualism. Establishing routines like brushing teeth every night after dinner helps toddlers feel secure and in control. Choice A, Negativism, refers to a child's oppositional behavior. Choice B, Diversionary activity, involves redirecting attention to something else. Choice C, Critical play, does not relate to the scenario of establishing a routine for the toddler.

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