The nurse must assess a 10-month-old infant. The infant is sitting on the father's lap and appears to be afraid of the nurse and of what might happen next. Which initial action by the nurse would be most appropriate?

Correct Answer: D

Rationale: Talking softly to the infant while taking him from his father would be the most appropriate initial action by the nurse in this situation. This approach allows the nurse to maintain communication with the infant to provide comfort and minimize fear or anxiety. By using a gentle tone and reassuring words, the nurse can help establish a sense of safety for the infant as he is transitioned from his father's lap to the examination table. This gradual and supportive approach is likely to facilitate a smoother assessment process and help build trust with the infant and the family.

Correct Answer: C

Rationale: The correct action to be taken when changing the tubing of a central line in the right subclavian vein is to close the roller clamp on the new tubing after priming it. This step is important to prevent air from entering the central line, which can lead to an air embolus. Proper priming and ensuring that the tubing is connected securely are essential steps in maintaining the integrity and safety of the central line system. Therefore, closing the roller clamp after priming the new tubing is crucial to prevent complications.

Correct Answer: B

Rationale: When administering IV fluids to clients with hypertension, the nurse must closely monitor the site and progress of the infusion every hour to ensure proper hydration and detect any signs of complications such as infiltration or infection. Checking the blood pressure every hour, as in choice A, may not be necessary unless specifically indicated by the healthcare provider. Checking the progress of the infusion once a day, as in choice C, does not provide adequate monitoring for a client with hypertension who may be at higher risk for fluid volume overload. Checking the client's pulse rate every hour, as in choice D, is important but does not directly address the immediate monitoring needs related to the administration of IV fluids.

Correct Answer: A

Rationale: In the presence of coma or unconsciousness, maintaining a clear airway is the major therapeutic measure to ensure adequate breathing and oxygenation. A clear airway is vital for the patient's survival and should be the priority to prevent respiratory distress or failure. Providing good nursing care is important for overall patient well-being, but ensuring a clear airway is crucial for immediate life support. Retention of a catheter is not a major therapeutic measure in the context of coma or unconsciousness unless specifically indicated for monitoring or treatment of underlying conditions. Therefore, the most critical intervention in this scenario is the maintenance of a clear airway.

Correct Answer: C

Rationale: The statement that is true about TPN and peripheral parenteral nutrition (PPN) is that TPN is often given to those with fluid restrictions, whereas PPN is used for those without constraints on their fluid intake. This is because TPN is a hypertonic solution that can cause fluid overload if given in large volumes, so it's typically reserved for patients who have fluid restrictions. On the other hand, PPN is a less concentrated solution that can be safely administered to patients without fluid restrictions.