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A nurse is assessing an 8-year-old child who has early indications of shock. After establishing and stabilizing the child's respirations, which of the following actions should the nurse take next?

Measure weight and height.

Insert an indwelling urinary catheter.

Initiate IV access.

Maintain ECG monitoring.

Answer and Explanation

The Correct Answer is C

A. Measuring weight and height is not an immediate priority in the management of shock.

B. Inserting an indwelling urinary catheter is not a priority in the early management of shock.

C. Initiating IV access is crucial for fluid resuscitation and medication administration in a child with shock.

D. While ECG monitoring is important, it is not as immediately necessary as establishing IV access for shock management.

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Correct Answer is C

Explanation

A. Abdominal pain rated 4 is moderate and should be managed but is not as immediately critical as hypotension.

B. A respiratory rate of 20/min is within normal limits for an adolescent and is not a priority finding.

C. Low blood pressure (hypotension) following blunt abdominal trauma is a concern for internal bleeding or hemorrhage. This is the priority finding and requires immediate intervention.

D. A heart rate of 72/min is normal and does not indicate immediate concern.

A. Elevate the head of the child's bed. B. Administer IM epinephrine to the child. C. Determine the allergen that caused the child's reaction D. Insert a large bore IV catheter for the child.

Correct Answer is B

Explanation

A. Elevating the head of the bed may be useful after airway management but is not the priority in anaphylaxis.

B. Administering IM epinephrine is the priority action in anaphylaxis, as it works rapidly to reverse the symptoms by constricting blood vessels, relaxing smooth muscles, and improving breathing.

C. Determining the allergen is important for future prevention, but the immediate priority is treating the reaction.

D. While establishing IV access is important for fluid resuscitation, it is not the priority over administering epinephrine in anaphylaxis.

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A nurse is assessing an 8-year-old child who has early indications of shock. After establishing and stabilizing the child's respirations, which of the following actions should the nurse take next?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is B

Explanation

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