when checking the intravenous iv site on a child the nurse should take which action
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Nursing Elites

ATI RN

RN Nursing Care of Children Online Practice 2019 A

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

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. A parent asks the nurse what would be the first indication that acute glomerulonephritis was improving. What would be the nurse's best response?

Correct answer: D

Rationale: Increased urine output is often the first sign that acute glomerulonephritis is improving, as it indicates a reduction in fluid retention and better kidney function. Stabilization of blood pressure and other symptoms typically follow.

3. At what age is the first dose of the hepatitis A vaccine recommended to be started?

Correct answer: A

Rationale: The correct answer is A: 1 year. The hepatitis A vaccine is now recommended for all children starting at age 1 year (i.e., 12 to 23 months). This is due to the recognition of hepatitis A as a significant child health problem, especially in areas with high infection rates. The virus is primarily spread through fecal-oral transmission, person-to-person contact, ingestion of contaminated food or water, and rarely through blood transfusion. Administering the first dose at 1 year helps protect children from this infection. Choices B and C are incorrect as the vaccine is not recommended at 1 month or 12 years. Choice D is also incorrect as the hepatitis A vaccine is recommended at a specific age to prevent the infection.

4. Which are included in the evaluation step of the nursing process? (Select all that apply.)

Correct answer: A

Rationale: The evaluation step involves determining if outcomes are met, modifying the plan if needed, and selecting alternative interventions if goals are not achieved.

5. The school nurse is evaluating the number of school-age children classified as obese. The nurse recognizes that the percentile of body mass index that classifies a child as obese is greater than which?

Correct answer: D

Rationale: A child with a BMI greater than the 95th percentile is classified as obese, according to standard growth charts used in pediatric practice.

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