A 12-year-old boy has broken his arm and is showing signs and symptoms of shock.
Which of the following would the nurse do first.
Draw blood for type and crossmatch.
Establish a suitable intravenous site.
Begin hyperventilation.
Provide oral analgesics as ordered.
The Correct Answer is B
Choice A rationale
Drawing blood for a type and crossmatch is a crucial step in preparing for potential blood product administration, but it is not the first action in managing a pediatric patient presenting with signs of shock. Immediate priorities involve securing vascular access to deliver intravenous fluids and medications to reverse the state of hypoperfusion.
Choice B rationale
Establishing a suitable intravenous (IV) site is the paramount first step in managing a patient in shock, especially hypovolemic shock from a broken arm, as it allows for immediate, rapid volume replacement with isotonic crystalloid fluids. Restoring intravascular volume is the primary goal to improve perfusion, making vascular access the initial life-saving priority.
Choice C rationale
Hyperventilation, which refers to an increased rate and depth of breathing, can lead to respiratory alkalosis and is not generally indicated for managing hypovolemic shock due to trauma unless there is evidence of severe head injury with signs of cerebral herniation. The immediate treatment for hypovolemic shock is fluid resuscitation, not manipulating respiratory rate.
Choice D rationale
While providing analgesics is important for pain management, it is a secondary intervention. Administering oral analgesics to a patient who is showing signs of shock is dangerous because compromised circulation can impair absorption, and the priority must remain the stabilization of hemodynamic status through fluid resuscitation via IV access.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
The infant's skin has a larger surface area to body weight ratio and a thinner stratum corneum (outermost layer) compared to an adult's. This increased permeability and surface area enhance the systemic absorption of topically applied medications, raising the risk of toxicity, a crucial consideration for safe drug administration in infants.
Choice B rationale
Infants actually have a greater body surface area relative to their weight compared to adults, which contributes to the enhanced systemic absorption of topical drugs. Therefore, the nurse must be more concerned, not less, about the body surface area and its role in drug absorption and potential toxicity.
Choice C rationale
The maturity and structure of the blood vessels are not the primary factors affecting the absorption rate of topical medications across the skin barrier. The most significant physiological factor influencing topical drug absorption in infants is the increased permeability of the epidermis and the large surface area to body weight ratio.
Choice D rationale
Infants have increased, not decreased, absorption rates of topical drugs due to the physiological immaturity of their skin barrier. This means the drug penetrates the skin and enters the bloodstream more readily, which necessitates cautious use and careful monitoring to prevent systemic adverse effects.
Correct Answer is B
Explanation
Choice A rationale
This statement reflects correct knowledge because head lice infestations, or pediculosis capitis, are highly contagious and spread through close contact or shared items, making it essential to check all household members to prevent reinfestation and ensure effective eradication of the parasites.
Choice B rationale
This statement supports a nursing diagnosis of knowledge deficit because it indicates a misconception that head lice are associated only with poor hygiene or low socioeconomic status, when in fact, lice infestation is unrelated to cleanliness and can occur in any population group through head-to-head contact.
Choice C rationale
This statement demonstrates correct knowledge because itching, particularly around the ears, neck, and scalp, is a common clinical manifestation of pediculosis capitis, caused by the louse saliva irritating the scalp, thus the parent correctly links the symptom to the new diagnosis.
Choice D rationale
This statement shows correct understanding of treatment because the nit comb is crucial for manually removing nits (lice eggs) that may remain attached to the hair shaft even after chemical pediculicide treatment, which often only kills live lice but not all the eggs.
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