The nurse is providing care to a school-age client admitted to ...

[cabate]

The nurse is providing care to a school-age client admitted to the emergency department following a motor vehicle crash. The client is exhibiting symptoms of hypovolemic shock. Which nursing interventions are appropriate for this client?
 
  1. Monitor hemoglobin and hematocrit.
  2. Monitor liver enzymes.
  3. Administer oxygen, as needed.
  4. Administer a dextrose solution.
  5. Monitor blood glucose.

Question 2

The nurse is preparing to discharge an infant with a congenital heart defect. The infant will be cared for at home by the parents until surgery. Which items will the nurse include in the discharge teaching for this infant and family?
 
  1. Allow the infant to feed for 60 minutes.
  2. Hold the infant at a 45 degree angle.
  3. Encourage frequent hand hygiene.
  4. Notify the health care provider for fever.
  5. Pump the breasts and feed with a bottle if weight gain is an issue.

[Swizqar]

Answer to Question 1

Correct Answer: 1,3,5
Rationale: Nursing care for a client experiencing hypovolemic shock is aimed at monitoring the child's condition and response to clinical therapy. It is appropriate for the nurse to monitor hemoglobin, hematocrit, and blood glucose. The nurse will also administer oxygen. The nurse will administer large volumes of crystalloid fluids (normal saline or lactated Ringer's), not dextrose. It is not necessary to monitor liver enzymes for this client.

Answer to Question 2

Correct Answer: 2,3,4,5
Rationale: Children are often managed at home until surgery. The parents should hold the infant at a 45 degree angle to decrease tachypnea. The parents should also encourage frequent hand hygiene to decrease the risk of infection. It is important to notify the health care provider for a fever, as the infant will be at risk for dehydration and digoxin toxicity. If the mother is breastfeeding and the infant is losing weight, the mother should be encouraged to pump the milk and feed the infant from a bottle, but each feeding should be limited to 30 minutes. Tube feedings may be needed for this infant to conserve calories expenditure.