An 18-month-old is admitted to the Emergency Department in hypovolemic shock. What would be the correct order of nursing interventions (assuming MD orders were written)?

Oxygen, IV fluid bolus of 10 ml/kg, medication to support cardiac function

Oxygen, IV fluid bolus of 20 ml/kg, medications to support cardiac function

IV at 2x maintenance, oxygen, medication to support cardiac function

Oxygen, medication to support cardiac function, IV fluid bolus of 20 ml/kg

Answer and Explanation

The Correct Answer is B

Choice A reason: This is not a good choice. IV fluid bolus of 10 ml/kg is not enough to restore the circulating volume and perfusion in a child with hypovolemic shock. The recommended initial fluid bolus for pediatric hypovolemic shock is 20 ml/kg of isotonic crystalloid solution.

Choice B reason: This is the correct choice. Oxygen, IV fluid bolus of 20 ml/kg, and medications to support cardiac function are the appropriate interventions for a child with hypovolemic shock. Oxygen is given to improve oxygenation and prevent tissue hypoxia. IV fluid bolus of 20 ml/kg is given to replace the lost fluid and blood volume and improve the blood pressure and cardiac output. Medications to support cardiac function may include inotropes, vasopressors, or antiarrhythmics, depending on the child's condition and the cause of the shock.

Choice C reason: This is not a good choice. IV at 2x maintenance is not sufficient to correct the hypovolemia and shock in a child. Maintenance fluids are given to prevent dehydration and electrolyte imbalance, but they are not enough to restore the hemodynamic stability and perfusion in a child with shock. A fluid bolus is needed to rapidly increase the intravascular volume and improve the vital signs.

Choice D reason: This is not a good choice. Oxygen and medication to support cardiac function are important, but they are not enough to reverse the hypovolemic shock in a child. A fluid bolus is the first and most essential intervention to correct the hypovolemia and shock in a child. Giving medication before fluid bolus may worsen the shock and cause adverse effects.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is A

Explanation

Choice A reason: This statement is correct, as standard precautions are the minimum level of infection control practices that should be applied to all patients, regardless of their diagnosis or presumed infection status. Standard precautions include hand hygiene, use of personal protective equipment (PPE), safe handling of sharps and contaminated items, and environmental cleaning. Standard precautions are sufficient for most patients with HIV, unless they have other infections that require additional precautions.

Choice B reason: This statement is incorrect, as droplet precautions are not required for patients with HIV, unless they have other infections that are transmitted by respiratory droplets, such as influenza, pertussis, or meningitis. Droplet precautions include wearing a surgical mask when within 3 feet of the patient, placing the patient in a private room or cohorting with other patients with the same infection, and limiting the movement of the patient outside the room.

Choice C reason: This statement is incorrect, as contact precautions are not required for patients with HIV, unless they have other infections that are transmitted by direct or indirect contact, such as Clostridioides difficile, scabies, or herpes simplex virus. Contact precautions include wearing gloves and gowns when entering the patient's room, placing the patient in a private room or cohorting with other patients with the same infection, and dedicating patient-care equipment to the patient or disinfecting it before use on another patient.

Choice D reason: This statement is incorrect, as airborne precautions are not required for patients with HIV, unless they have other infections that are transmitted by airborne particles, such as tuberculosis, measles, or chickenpox. Airborne precautions include wearing a respirator or N95 mask when entering the patient's room, placing the patient in a negative-pressure isolation room with the door closed, and limiting the movement of the patient outside the room.

A. Chromosomal mutation is the cause. B. Slow feeding will be necessary for a few months. C. Dietary restrictions will be required throughout childhood. D. Surgery will be necessary.

Correct Answer is D

Explanation

Choice A reason: Chromosomal mutation is not the cause of hypertrophic pyloric stenosis. The exact cause is unknown, but it may be related to genetic, environmental, or hormonal factors.

Choice B reason: Slow feeding will not be sufficient to manage hypertrophic pyloric stenosis. The infant will have persistent vomiting, dehydration, and weight loss due to the obstruction of the pylorus.

Choice C reason: Dietary restrictions will not be effective for hypertrophic pyloric stenosis. The infant will not be able to tolerate any oral intake until the pylorus is surgically corrected.

Choice D reason: Surgery will be necessary to treat hypertrophic pyloric stenosis. The surgery is called pyloromyotomy, which involves cutting the thickened muscle of the pylorus to allow the stomach to empty into the duodenum.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

An 18-month-old is admitted to the Emergency Department in hypovolemic shock. What would be the correct order of nursing interventions (assuming MD orders were written)?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

When planning care for a patient with HIV, which of the following precautions should be implemented?

Correct Answer is A

Explanation

The mother of an infant with hypertrophic pyloric stenosis asks the nurse many questions about the problem. When answering these questions, the nurse should convey the idea that:

Correct Answer is D

Explanation

You are discussing prevention of infective endocarditis with parents of a child with a complex congenital heart defect. A critical teaching point to emphasize includes:

The nurse is discussing feeding with parents of a 1-year-old. Important teaching points should include:

A 10-month-old infant has been confirmed with HIV. The nurse knows that:

A three-year-old is admitted to the pediatric medical unit with acute Kawasaki disease. What signs and symptoms are you most likely to note as you do your intake assessment?

A child with severe gastroesophageal reflux disease (GERD) is scheduled for Nissen fundoplication. Postoperative nursing management should include (select all that apply):

A 3-year-old child with a complex cardiac defect is admitted with infective endocarditis. Management (in what order) would be:

A six-week-old infant is one day post-op for a pyloromyotomy for pyloric stenosis. The infant is started on the first oral feedings. Which of the following actions by the mother would most indicate a need for further nursing interventions?

A child in compensated shock will show which symptoms?