the nurse is caring for a very low birth weight vlbw infant with a peripheral intravenous infusion what nursing considerations regarding infiltration
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Nursing Elites

ATI RN

Nursing Care of Children ATI

1. 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?

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.

2. Because children younger than 5 years are egocentric, the nurse should do which when communicating with them?

Correct answer: A

Rationale: Focusing communication directly on the child aligns with their egocentric nature and helps engage them in the conversation.

3. A nurse must do a venipuncture on a 6-year-old child. What consideration is important in providing atraumatic care?

Correct answer: B

Rationale: Showing the child the equipment before the procedure helps build trust and reduces fear. Using an 18-gauge needle is too large for a child, and multiple attempts can increase trauma. Restraining completely can increase fear and anxiety.

4. A 7-year-old has been diagnosed with cystic fibrosis. Chest physiotherapy has been ordered. What information should the nurse give to the parents regarding when chest physiotherapy is done?

Correct answer: D

Rationale: The correct answer is D: 'Before meals'. Chest physiotherapy should be performed before meals to reduce the risk of vomiting and to ensure that the airways are clear for effective nutrition. Choices A, B, and C are incorrect because chest physiotherapy is ideally done before meals to optimize its benefits and avoid complications associated with timing.

5. A child is admitted to the hospital with acute renal failure. The parents ask about the prognosis for acute renal failure. The nurse’s response should be based on which statement about acute renal failure?

Correct answer: C

Rationale: The correct answer is C: Acute renal failure in children is often reversible, especially when the underlying cause is identified and treated promptly. It does not always lead to chronic renal failure or the need for a kidney transplant. Choice A is incorrect as prophylactic antibiotics for life are not a standard treatment for acute renal failure. Choice B is incorrect as acute renal failure does not always progress to chronic renal failure. Choice D is incorrect as not all children with acute renal failure will eventually require a kidney transplant.

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