Nurse Roy is administering total parental nutrition (TPN) through a peripheral I.V. line to a school-age child. What’s the smallest amount of glucose that’s considered safe and not caustic to small veins, while also providing adequate TPN?

Correct Answer: B

Rationale: In pediatric nursing, administering TPN through a peripheral I.V. line requires careful consideration of the glucose concentration to prevent vein irritation or damage. The correct answer is B) 10% glucose because it is the smallest concentration that provides adequate nutrition without causing irritation to small veins. Option A) 5% glucose is too dilute to provide sufficient TPN support, especially for a school-age child who may have higher nutritional needs. Option C) 15% and D) 17% glucose concentrations are too concentrated and can be caustic to small veins, leading to phlebitis or thrombophlebitis. Educationally, understanding the appropriate glucose concentration for TPN in pediatric patients is crucial for safe and effective nursing practice. Nurses must be aware of the potential complications of incorrect glucose concentrations to ensure optimal patient outcomes. This knowledge helps in providing quality care and preventing harm to pediatric patients receiving TPN through peripheral lines.

Correct Answer: D

Rationale: In this scenario, the correct answer is D) Gown, gloves, mask, and eye goggles or eye shield. The primary mode of transmission for severe acute respiratory syndrome (SARS) is through respiratory droplets. Therefore, it is crucial for the nurse to wear comprehensive personal protective equipment to prevent exposure. Option A) Gloves alone are not sufficient to protect against respiratory droplets that could potentially transmit SARS. Option B) Gown and gloves provide some protection, but a mask and eye protection are necessary due to the airborne nature of the virus. Option C) Gown, gloves, and mask offer good protection, but eye protection is also essential to prevent exposure through the mucous membranes of the eyes. Educationally, understanding the appropriate personal protective equipment for different infectious diseases is crucial for healthcare professionals to ensure their safety and the safety of their patients. In pediatric nursing, where children may not always exhibit typical symptoms, it is especially important to take all necessary precautions to prevent the spread of infectious diseases.

Correct Answer: A

Rationale: In this scenario, the correct nursing diagnosis that takes priority is "A) Ineffective airway clearance related to edema." The rationale behind this choice is that with third-degree burns involving the hands, face, and chest, there is a high risk of edema (swelling) in the upper airway, which can compromise the child's ability to breathe effectively. Maintaining a clear airway is of utmost priority to ensure oxygenation and ventilation, which are essential for life. Option B, "Disturbed body image related to physical appearance," is not the priority nursing diagnosis in this acute situation. While body image is important for psychosocial well-being, it takes a back seat to addressing immediate physiological needs like airway clearance. Option C, "Impaired urinary elimination related to fluid loss," is also not the priority at this moment. While fluid loss is a concern in burn patients, the immediate threat to life posed by compromised airway clearance takes precedence. Option D, "Risk for infection related to epidermal disruption," is a valid concern in burn patients, but in the immediate aftermath of a burn injury, addressing airway patency is more critical to prevent respiratory distress and potential respiratory failure. In an educational context, understanding the prioritization of nursing diagnoses based on the urgency of the patient's needs is crucial in pediatric nursing, especially in emergency situations like severe burn injuries. This question highlights the importance of recognizing and addressing life-threatening complications promptly to ensure positive patient outcomes.

Correct Answer: A

Rationale: In pediatric nursing, understanding congenital heart defects like ventricular septal defects (VSDs) is crucial. A VSD allows blood to shunt left to right, causing increased pulmonary flow and no cyanosis. This is because the higher pressure in the left ventricle pushes oxygenated blood through the defect into the right ventricle and out to the pulmonary circulation. This shunting of blood does not cause cyanosis because oxygen-rich blood is still reaching the systemic circulation. Option B is incorrect because if blood were to shunt right to left, it would bypass the lungs, resulting in decreased pulmonary flow and cyanosis due to poorly oxygenated blood entering the systemic circulation. Option C is incorrect as VSDs typically result in a left-to-right shunt due to the pressure differences between the ventricles. Option D is also incorrect because a VSD does not directly affect the pressure in the left atrium. Educationally, understanding the hemodynamics of VSDs is crucial for nurses caring for pediatric patients with congenital heart defects. Recognizing the impact of VSDs on pulmonary blood flow and oxygenation helps nurses provide appropriate interventions and education to support optimal outcomes for these patients.

Correct Answer: B

Rationale: In pediatric nursing, administering medications like digoxin to infants requires precision and careful monitoring due to their unique physiological characteristics. The most appropriate nursing action related to the administration of digoxin to an infant is option B) Withholding a dose if the apical heart rate is less than 100 beats/min. This is the correct answer because digoxin is a medication that affects the heart, specifically by increasing the strength of the heart muscle contractions. Monitoring the heart rate before administering digoxin is crucial because it can cause serious complications like bradycardia. If the infant's heart rate is already below 100 beats/min, giving digoxin could further slow down the heart rate, leading to adverse effects. Option A is incorrect because simply counting the apical rate does not provide enough information to determine if it is safe to administer digoxin. Option C is incorrect because repeating a dose if the child vomits increases the risk of toxicity since the full dose may have already been absorbed. Option D is incorrect because while checking respiratory rate and blood pressure are important assessments, they are not the primary indicators for determining the appropriateness of administering digoxin in an infant. Educationally, understanding the rationale behind withholding digoxin if the heart rate is below 100 beats/min emphasizes the importance of individualized care in pediatric pharmacology. It highlights the need for nurses to be vigilant in monitoring vital signs before administering medications that can have significant cardiac effects in pediatric patients.