Nursing Elites

1. When checking the intravenous (IV) site on a child, the nurse should take which action?

• A. Look at the site.
• B. Ask the child if the site hurts.
• C. Look at the site while palpating the area.
• D. Take all the tape off, assess the site, and redress.

Correct answer: C

Rationale: Looking at and palpating the IV site helps assess for signs of infiltration or infection, such as swelling, redness, or pain. Simply looking or asking the child may miss subtle signs, and removing all the tape unnecessarily disrupts the site.

2. The nurse is assessing a 3-year-old child. Which assessment finding would the nurse identify as abnormal?

• A. Pedals tricycle without assistance
• B. Unscrews a bolt on a toy
• C. Falls when bending over to touch toes
• D. Builds a tower of 10 cubes

Correct answer: C

Rationale: The correct answer is C. Falling when bending over to touch toes could indicate a developmental delay or a balance issue that may need further assessment. Choices A, B, and D are typical developmental milestones for a 3-year-old child. Pedaling a tricycle without assistance, unscrewing a bolt on a toy, and building a tower of 10 cubes are all age-appropriate activities for a child of this age.

3. What is an advantage of the ventrogluteal muscle as an injection site in young children?

• A. Easily accessible from many directions
• B. Free of significant nerves and vascular structures
• C. Can be used until the child reaches a weight of 9 kg (20 lb)
• D. Increased subcutaneous fat, which provides sustained drug absorption

Correct answer: B

Rationale: The ventrogluteal site is free of significant nerves and vascular structures, making it a safer choice for intramuscular injections in young children compared to other sites that may be more prone to complications.

4. 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.

5. The mother of a child with type 1 diabetes asks the nurse why her child cannot avoid all those ‘shots’ and take pills like an uncle does. How should the nurse respond?

• A. The pills work with adult pancreases only.
• B. Your child needs insulin replaced, and the oral hypoglycemic only add to an existing supply of insulin.
• C. The drugs affect fat and protein metabolism, not sugar.
• D. Perhaps when your child is older the pancreas will produce its own insulin, and then your child can take oral hypoglycemic agents.

Correct answer: B

Rationale: The correct answer is B. Children with type 1 diabetes require insulin replacement because their pancreas produces little or no insulin. Oral hypoglycemics used in type 2 diabetes work by improving the effectiveness of insulin the body already makes, which is not sufficient in type 1 diabetes. Choice A is incorrect because the issue is not about the pancreas being adult or child-specific but rather the type of diabetes. Choice C is incorrect because it misstates the mechanism of action of the medications. Choice D is incorrect because it provides inaccurate information about the potential for the child's pancreas to produce insulin in the future, which is unlikely in type 1 diabetes.

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