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.

Answer and Explanation

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.

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Correct Answer is D

Explanation

Choice A reason: Pulselessness is not a sign of normal AV fistula function; a palpable pulse should be present.
Choice B reason: An ecchymotic area suggests bruising and is not indicative of normal function.
Choice C reason: Redness may indicate inflammation or infection, not normal function.
Choice D reason: This is the correct choice. An enlarged vein is typical for an AV fistula and indicates good blood flow through the fistula.

A. "A lack of prenatal care is a known cause of autism, but there is no way you could have predicted this." B. "The specific cause of autism is unknown; however, it is known to be associated with problems in the structure of and chemicals in the brain." C. "Although autism is genetically inherited, if you didn't have testing, you could not have known this would happen." D. "Autism is a rare disorder. Your other children shouldn't be affected."

Correct Answer is B

Explanation

Choice A reason: This statement is incorrect and could potentially increase feelings of guilt, as a lack of prenatal care is not a known cause of autism.

Choice B reason: This statement is accurate and can help alleviate guilt by explaining that autism is not caused by something the parents did or did not do.

Choice C reason: While it's true that parents without genetic testing could not have known, this statement does not address the feelings of guilt regarding causation.

Choice D reason: This statement is misleading because autism is not considered rare, and siblings can have an increased risk of autism spectrum disorders. It does not provide accurate information or address the parents' feelings of guilt.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is assessing a patient’s arteriovenous (AV) fistula. Which finding provides evidence of its normal function?

Correct Answer is D

Explanation

Which statement by the nurse would best help alleviate parental guilt about their child, George, who has been recently diagnosed with autism?

Correct Answer is B

Explanation

The nurse obtains a fingerstick blood glucose level using bedside lancet/glucose meter equipment from a client with a prescribed sliding scale insulin protocol. The meter indicates 56 mg/dL (3.12 mmol/L). At this time, which intervention should the nurse implement first?

Which nursing intervention is most appropriate for a school-age child with congenital heart block who codes in the emergency department (ED), while the parents witness the resuscitation scene?

What notable sign most likely indicates increased intracranial pressure in an infant?

Which of the following is of primary importance for a child who is admitted to the PICU for DKA (diabetic ketoacidosis)?

Nursing care of a child diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH) should include which of the following?

Which nursing diagnosis takes priority for a 15-year-old child with third-degree burns of the hands, face, and chest?

When developing a plan of care for a hospitalized child, the nurse knows that children in which age group are most likely to view illness as a punishment for misdeeds?

A parent asks the nurse if there is anything that can be done to reduce the pain that his 2-year-old experiences each morning when blood is drawn for lab studies. Which intervention is the best choice for the nurse to implement based on the parent's concern?