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.

Nursing Test Bank

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Correct Answer is A

Explanation

Choice A reason: A third-degree circumferential burn can compromise blood flow, posing an immediate risk for altered tissue perfusion, which can lead to tissue necrosis and limb loss.

Choice B reason: While impaired physical mobility is a concern, it is not as immediately life-threatening as altered tissue perfusion.

Choice C reason: Nutritional needs are important for healing, but the immediate threat to life from a third-degree burn is the risk for altered tissue perfusion.

Choice D reason: Fluid imbalance is a significant concern due to the potential for burn-induced edema and dehydration; however, the most immediate life-threatening issue is altered tissue perfusion.

A. Calcium intake should be restricted. B. The child should eat three large meals per day and limit snacks between meals. C. Potassium intake should be limited. D. Sodium intake should be increased.

Correct Answer is C

Explanation

Choice A reason: Restricting calcium intake is not typically recommended for children with chronic renal failure as they may already be at risk for bone disease due to altered calcium metabolism.
Choice B reason: Eating three large meals per day and limiting snacks is not specific dietary advice for chronic renal failure; nutritional needs should be tailored to the individual.
Choice C reason: This is the correct choice. In chronic renal failure, the kidneys may not be able to remove excess potassium, leading to hyperkalemia, which can be dangerous.
Choice D reason: Increasing sodium intake is not generally recommended for chronic renal failure as it can contribute to hypertension and fluid retention.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

What is the highest priority nursing diagnosis for a pediatric client with a third-degree circumferential burn of the right arm?

Correct Answer is A

Explanation

The nurse is teaching a child experiencing chronic renal failure about his diet. The nurse should discuss which of the following dietary recommendations?

Correct Answer is C

Explanation

A client with an arterial ischemic leg ulcer is being discharged from the hospital. Which instruction is most important for the nurse to include in this client's discharge teaching plan?

What is the most appropriate action for the nurse to take, given that a 4-month-old infant, brought in for a routine checkup and vaccinations, was exposed to a sibling with the flu?

Which is the best nursing response to give a parent about contacting the physician regarding a 4-month-old infant with diarrhea?

At which stage of development are children able to understand the permanence of death?

For an adolescent client diagnosed with rheumatoid arthritis, which non-pharmacological measure is most appropriate to reduce joint pain?

Which is an expected physical assessment finding for an adolescent with a diagnosis of Hodgkin’s disease?

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

An infant has been admitted to the Neonatal Intensive Care Unit (NICU) with congenital gastroschisis. Which intervention should the nurse perform first upon admission to the unit?