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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Nursing Elites

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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. What is the primary symptom of congenital diaphragmatic hernia in a newborn?

Correct answer: C

Rationale: Absent breath sounds on the affected side are a primary symptom of congenital diaphragmatic hernia. Cyanosis, bradycardia, and tachypnea may also be present but are not the primary symptom. Cyanosis is a bluish discoloration of the skin due to poor oxygenation, bradycardia is a slower than normal heart rate, and tachypnea is rapid breathing.

3. The nurse is planning to counsel family members as a group to assess the family's group dynamics. Which theoretical family model is the nurse using as a framework?

Correct answer: C

Rationale: Family systems theory views the family as an interconnected system where changes in one member affect the entire family, making it ideal for assessing group dynamics.

4. The nurse is assessing a 3-day-old breastfed newborn who weighed 3400 g (7 pounds, 8 oz) at birth. The infant’s mother is now concerned because the infant weighs 3147 g (6 pounds, 15 oz). The most appropriate nursing intervention is what?

Correct answer: B

Rationale: A neonate normally loses about 10% of the birth weight by age 3 to 4 days. The birth weight is usually regained by the 10th day of life. In this case, the weight loss from 3400 g to 3147 g is within the expected range. Therefore, the most appropriate action is to explain to the mother that this weight loss is within normal limits. Choice A is incorrect because supplemental feedings of formula are not indicated for this expected weight loss in a breastfed newborn. Choice C is incorrect as there is no evidence to suggest excessive weight loss at this point. Choice D is unnecessary at this stage and may not align with the current situation of normal weight loss post-birth.

5. What pathologic process is believed to be responsible for the development of postinfectious glomerulonephritis?

Correct answer: B

Rationale: Postinfectious glomerulonephritis is typically caused by immune complex deposition in the glomeruli following a streptococcal infection. This immune response leads to inflammation and impaired kidney function.

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