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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Clinicians should be involved in discussions about the child’s prognosis to ensure that the family receives clear, compassionate information for decision-making.
B. Palliative care can and should be introduced earlier in the course of the illness, not just when the child is expected to live less than 6 months.
C. Parents expressing hope for survival do not necessarily reject palliative care. Palliative care can focus on comfort and quality of life even when there is still hope for recovery.
D. Palliative care should be integrated with curative care, as it can improve the quality of life while still pursuing treatment options.
Correct Answer is B
Explanation
A. A urinary output of 100 mL/hr is within the expected range for a 10-year-old and does not indicate septic shock. In early septic shock, urinary output is often preserved or mildly decreased.
B. An elevated temperature (fever) is a hallmark of early septic shock as the body mounts an inflammatory response to infection. Fever often accompanies early sepsis in pediatric patients.
C. Blood pressure may remain normal or slightly elevated in early septic shock due to compensatory mechanisms. A BP of 130/90 mm Hg is not a defining feature.
D. A heart rate of 60/min is abnormally low for a 10-year-old and could indicate late-stage shock or other complications. In early septic shock, tachycardia (elevated heart rate) is typically observed.
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