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: Murmur, tachycardia, and low erythrocyte sedimentation rate are not specific signs of Kawasaki disease. They may indicate other cardiac or inflammatory conditions.
Choice B reason: Abdominal pain, vomiting, and restlessness are not typical signs of Kawasaki disease. They may suggest other gastrointestinal or neurological problems.
Choice C reason: Coarse breath sounds, abnormal ECG, and joint pain are not common signs of Kawasaki disease. They may indicate other respiratory, cardiac, or rheumatic disorders.
Choice D reason: This is the correct choice. Fever, "strawberry tongue" and peeling palms and soles are characteristic signs of Kawasaki disease, which is a rare but serious condition that causes inflammation of the blood vessels. Other signs include red eyes, swollen lips, rash, and swollen lymph nodes.
Correct Answer is A
Explanation
Choice A reason: This statement is correct, as hydrostatic reduction of telescoped bowel with an air or saline enema is the preferred treatment for intussusception, which is a condition where a segment of the intestine slides into another segment, causing obstruction, inflammation, and ischemia. The enema can help to push the invaginated bowel back to its normal position, relieve the obstruction, and restore the blood flow. The procedure is safe, effective, and minimally invasive, and can avoid the need for surgery.
Choice B reason: This statement is incorrect, as hydrostatic reduction of telescoped bowel with an air or saline enema is not a false statement, but a true one. The nurse should be aware of the indications, contraindications, and complications of this procedure, and monitor the child's vital signs, abdominal distension, bowel sounds, and stool output before, during, and after the enema. The nurse should also educate the parents about the signs and symptoms of recurrence, such as abdominal pain, vomiting, or bloody stools.
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