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 A

Explanation

Choice A reason: Allowing parents to hold their infant is a compassionate act that acknowledges their need for closure and can help them begin the grieving process.

Choice B reason: Interviewing parents to determine the cause of the incident is not considered supportive care; it may be part of an investigation but does not provide comfort.

Choice C reason: Providing mementos can be a cherished way for parents to remember their infant and can offer some solace during a difficult time.

Choice D reason: Advising parents about the necessity of an autopsy is not supportive care; it is a medical decision that should be discussed with sensitivity to the parents' feelings and needs. Autopsies can be important for understanding SIDS and preventing future occurrences.

A. Take the child on a tour of the whole unit to familiarize with the surroundings. B. Admit the child to a four-bed room to allow interaction with peers. C. Orient the child to the hospital room. D. Take the child to the playroom immediately to participate in the arts and crafts activity.

Correct Answer is C

Explanation

Choice A reason: Taking the child on a tour might be overwhelming and increase anxiety due to the new environment and sensory overload.

Choice B reason: Placing the child in a four-bed room could lead to overstimulation and discomfort due to the presence of multiple unfamiliar people.

Choice C reason: Orienting the child to the hospital room provides a safe and controlled environment, allowing for gradual adjustment to the new setting.

Choice D reason: Immediately taking the child to the playroom for arts and crafts might be too stimulating and could exacerbate stress rather than ease the transition.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which two interventions are considered supportive care for a family whose infant has died from sudden infant death syndrome (SIDS)?

Correct Answer is A

Explanation

A school-age client diagnosed with autism is admitted to the hospital because of recent vomiting and diarrhea. Which intervention by the nurse is most appropriate upon admission?

Correct Answer is C

Explanation

The nurse is planning care for an infant after a cleft-lip repair. Which of the following is NOT an appropriate nursing intervention for this infant?

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A 6-year-old child has been sent to the school nurse for wetting her pants three times in the past 2 days. The nurse should recommend that this child be evaluated for which complication first?

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

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

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The nurse is giving a health promotion class to adolescents. The nurse will be sure to include information regarding the leading cause of death in adolescents aged 15 and up.

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