the nurse determines that a childs intravenous infusion has infiltrated the infused solution is a vesicant what is the most appropriate nursing action
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RN Nursing Care of Children Online Practice 2019 A

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?

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. Which congenital heart defect causes a "boot-shaped" heart on a chest x-ray?

Correct answer: A

Rationale: The correct answer is A: Tetralogy of Fallot. Tetralogy of Fallot, a congenital heart defect with four distinct abnormalities, often presents with a "boot-shaped" heart on chest x-ray due to right ventricular hypertrophy. This characteristic finding is due to the specific combination of defects in this condition. Coarctation of the aorta (choice B), Transposition of the great arteries (choice C), and Ventricular septal defect (choice D) do not typically result in a "boot-shaped" heart on a chest x-ray like Tetralogy of Fallot does.

3. The nurse is administering activated charcoal to a preschool child with acetaminophen (Tylenol) poisoning. What potential complications from the use of activated charcoal should the nurse plan to assess for?

Correct answer: C

Rationale: Common complications of activated charcoal administration include diarrhea and vomiting. Intestinal obstruction can occur if the charcoal forms a mass in the intestines. Fluid retention is less likely and not typically a complication associated with activated charcoal.

4. The nurse's approach when introducing hospital equipment to a preschooler who seems afraid should be based on which principle?

Correct answer: A

Rationale: Preschoolers may engage in magical thinking and believe inanimate objects are alive, so the nurse should explain the equipment in a way that reduces fear.

5. Which clinical manifestations should the nurse anticipate when assessing a child for hypoglycemia?

Correct answer: D

Rationale: The correct answer is D: 'Shaky feeling and dizziness.' Hypoglycemia in children often presents with symptoms like shakiness, dizziness, sweating, hunger, and irritability. These symptoms occur because the brain and body are deprived of the glucose they need to function properly. Choices A, B, and C are incorrect because lethargy, thirst, nausea, and vomiting are not typically primary manifestations of hypoglycemia in children.

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