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 C

Explanation

The correct answer is: c. In an emergency, a court order can be obtained for the patient to receive blood transfusions.

Choice A: The patient can only receive blood that has been donated by family members.

Jehovah’s Witnesses refuse blood transfusions, including those from family members, due to their religious beliefs. They believe that both the Old and New Testaments command them to abstain from blood (Genesis 9:4; Leviticus 17:10; Deuteronomy 12:23; Acts 15:28, 29). Therefore, this option is incorrect.

Choice B: Under no circumstances will the patient receive blood products.

While Jehovah’s Witnesses generally refuse blood transfusions, there are exceptional circumstances where medical professionals can seek a court order to administer blood transfusions, especially in life-threatening situations involving minors. Thus, this statement is not entirely accurate.

Choice C: In an emergency, a court order can be obtained for the patient to receive blood transfusions.

In life-threatening emergencies, especially involving minors, courts can intervene and issue orders to administer necessary medical treatments, including blood transfusions, despite parental objections based on religious beliefs. This ensures the child’s right to life and health is protected. Therefore, this is the correct answer.

Choice D: The patient can receive volume expanders.

Volume expanders can be used to increase blood volume and maintain circulation, but they do not carry oxygen or replace lost blood cells. While they are an option for managing blood loss, they are not a substitute for blood transfusions in severe cases of anemia or blood loss, which are common in leukemia patients. Thus, this option is not entirely correct.

A. "Does the child complain of headaches?" B. "How much candy and sweets does your child consume daily?" C. "How much exercise does the child get?" D. "Has the child experienced nocturia or bedwetting?"

Correct Answer is D

Explanation

Choice A reason: While headaches can be a symptom of high blood sugar, they are not as specific as other symptoms for diabetes.
Choice B reason: Asking about candy and sweets consumption is less relevant as type 1 DM is not caused by diet.
Choice C reason: Exercise is important for overall health but is not a diagnostic indicator of type 1 DM.
Choice D reason: This is the correct choice. Nocturia and bedwetting are common symptoms of type 1 DM due to excess urination caused by high blood sugar levels.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A four-year-old patient has been diagnosed with leukemia. The patient's parents, who follow the Jehovah's Witness faith, inform the physician that they will not approve any type of blood transfusions. The pediatric nurse is aware that:

Correct Answer is C

Explanation

When admitting a child with suspected type 1 diabetes mellitus (DM), which of the following questions should the nurse ask the parents?

Correct Answer is D

Explanation

An 17-year-old with a rash and itching in the groin area is concerned that he has contracted a sexually transmitted disease and does not want his parents to find out. The nurse's best response is:

After surgery for the correction of bilateral congenital clubfeet, an infant returns with bilateral long-leg casts. The toes on both feet are edematous, yet there is color, sensitivity, and movement. What is the most appropriate action by the nurse?

Which client in the pediatric intensive care unit (PICU) would most benefit from palliative care?

A client presents with the onset of a severe headache, fever, nuchal rigidity, and a petechial rash on arms and legs. The nurse recognizes the client is exhibiting symptoms of which condition?

When planning care for a client newly diagnosed with open-angle glaucoma, the nurse identifies a priority nursing problem of visual sensory-perceptual alterations. This problem is based on which etiology?

What is the best response by the nurse when the parents ask about the paralysis associated with Guillain-Barré Syndrome, which has affected the respiratory muscles and requires mechanical ventilation for their child?

An infant with tetralogy of Fallot is having a hypercyanotic episode ('tet' spell). Which three nursing interventions are appropriate for the nurse to implement for this infant?

The nurse prepares a teaching plan for an adult patient with metabolic syndrome. Which findings should the nurse address to help the patient reduce the risk for diabetes mellitus and vascular disease? (Select all that apply.)