A 4-month-old is brought to the emergency department with severe dehydration. The heart rate is 198, and the blood pressure is 68/38. The infant's anterior fontanel is sunken. The nurse notes that the infant does not cry when the intravenous line is inserted. The child's parents state that she has not "held anything down" in 18 hours. The nurse obtains a finger-stick blood sugar of 94. Which action would the nurse expect to do immediately?
Administer a bolus of D10W.
Offer the child a bottle of an oral rehydration solution such as Pedialyte.
Administer a bolus of hypertonic saline.
Administer a bolus of normal saline.
The Correct Answer is D
Choice A reason: Administering a bolus of D10W is not the first-line treatment for severe dehydration and may not address the immediate fluid needs of the infant.
Choice B reason: Offering an oral rehydration solution is not appropriate for an infant with severe dehydration and a compromised ability to hold down fluids.
Choice C reason: Administering a bolus of hypertonic saline is not typically the initial treatment for dehydration and could potentially worsen the infant's condition.
Choice D reason: This is the correct choice. Administering a bolus of normal saline is the immediate action to treat severe dehydration and restore circulatory volume.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: This is the correct choice. Congestive heart failure can occur in chronic renal failure due to fluid overload and the inability of the kidneys to manage fluid balance.
Choice B reason: Metabolic alkalosis is not typically a major complication of chronic renal failure; metabolic acidosis is more common due to the accumulation of acids in the body.
Choice C reason: Excessive excretion of blood urea nitrogen is not a complication; rather, in renal failure, the kidneys cannot excrete urea nitrogen effectively.
Choice D reason: Hypokalemia (low potassium) can occur, but it is not as major a complication as congestive heart failure in the context of chronic renal failure.
Correct Answer is C
Explanation
Choice A reason: Fever is a concern, but it is not the most immediate sign of dehydration.
Choice B reason: While loose stools are a symptom of diarrhea, the frequency mentioned does not necessarily indicate an emergency.
Choice C reason: This is the correct choice. Lack of a wet diaper for 8 hours can indicate dehydration, which is an emergency in infants.
Choice D reason: Longer naps may not be directly related to diarrhea and do not warrant immediate contact with a pediatrician.
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