An 18-month-old is admitted to the Emergency Department in hypovolemic shock. What would be the correct order of nursing interventions (assuming MD orders were written)?
Oxygen, IV fluid bolus of 10 ml/kg, medication to support cardiac function
Oxygen, IV fluid bolus of 20 ml/kg, medications to support cardiac function
IV at 2x maintenance, oxygen, medication to support cardiac function
Oxygen, medication to support cardiac function, IV fluid bolus of 20 ml/kg
The Correct Answer is B
Choice A reason: This is not a good choice. IV fluid bolus of 10 ml/kg is not enough to restore the circulating volume and perfusion in a child with hypovolemic shock. The recommended initial fluid bolus for pediatric hypovolemic shock is 20 ml/kg of isotonic crystalloid solution.
Choice B reason: This is the correct choice. Oxygen, IV fluid bolus of 20 ml/kg, and medications to support cardiac function are the appropriate interventions for a child with hypovolemic shock. Oxygen is given to improve oxygenation and prevent tissue hypoxia. IV fluid bolus of 20 ml/kg is given to replace the lost fluid and blood volume and improve the blood pressure and cardiac output. Medications to support cardiac function may include inotropes, vasopressors, or antiarrhythmics, depending on the child's condition and the cause of the shock.
Choice C reason: This is not a good choice. IV at 2x maintenance is not sufficient to correct the hypovolemia and shock in a child. Maintenance fluids are given to prevent dehydration and electrolyte imbalance, but they are not enough to restore the hemodynamic stability and perfusion in a child with shock. A fluid bolus is needed to rapidly increase the intravascular volume and improve the vital signs.
Choice D reason: This is not a good choice. Oxygen and medication to support cardiac function are important, but they are not enough to reverse the hypovolemic shock in a child. A fluid bolus is the first and most essential intervention to correct the hypovolemia and shock in a child. Giving medication before fluid bolus may worsen the shock and cause adverse effects.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: This is not a good choice. Septic shock is a type of distributive shock that occurs when an infection causes a systemic inflammatory response that leads to vasodilation, hypotension, and organ dysfunction. Septic shock is not the most common type of shock in children, although it can be a serious and life-threatening condition.
Choice B reason: This is not a good choice. Anaphylactic shock is a type of distributive shock that occurs when an allergic reaction causes a severe and rapid hypersensitivity response that leads to bronchoconstriction, angioedema, and hypotension. Anaphylactic shock is not the most common type of shock in children, although it can be a medical emergency that requires immediate treatment.
Choice C reason: This is not a good choice. Distributive shock is a broad category of shock that occurs when there is a loss of vascular tone and blood volume distribution that leads to hypoperfusion and tissue hypoxia. Distributive shock can be caused by various factors, such as sepsis, anaphylaxis, neurogenic injury, or adrenal insufficiency. Distributive shock is not the most common type of shock in children, although it can be a complex and challenging condition to manage.
Choice D reason: This is the correct choice. Hypovolemic shock is the most common type of shock in children. Hypovolemic shock occurs when there is a loss of blood or fluid volume that leads to decreased preload, cardiac output, and blood pressure. Hypovolemic shock can be caused by various factors, such as hemorrhage, dehydration, vomiting, diarrhea, or burns. Hypovolemic shock can be a life-threatening condition that requires prompt fluid resuscitation and correction of the underlying cause.
Correct Answer is A
Explanation
Choice A reason: This statement is correct, as ART is the standard treatment for HIV infection in infants and children, regardless of their age, clinical status, or CD4 count. ART can suppress the viral load, improve the immune function, prevent opportunistic infections, and prolong the survival and quality of life of the infant.
Choice B reason: This statement is incorrect, as delaying ART until the infant turns 12 months old can increase the risk of disease progression, mortality, and drug resistance. The nurse should explain to the parents that early initiation of ART is recommended for all infants with HIV, as they have a high viral load and a rapid decline of CD4 cells.
Choice C reason: This statement is incorrect, as waiting for the infant to have a clinical manifestation of AIDS before starting ART can be too late and ineffective. The nurse should inform the parents that AIDS is the most advanced stage of HIV infection, characterized by severe immunosuppression and life-threatening opportunistic infections. The nurse should emphasize the importance of early diagnosis and treatment of HIV to prevent the development of AIDS.
Choice D reason: This statement is incorrect, as the mother's HIV status is not mandatory to be tested, but voluntary and confidential. The nurse should respect the mother's right to privacy and autonomy, and offer her counseling and testing services if she agrees. The nurse should also educate the mother about the modes of transmission, prevention, and treatment of HIV.
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