Elevate NCLEX Preparation # 09

Elevate NCLEX Preparation # 09

December 09, 2024

Monday

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A 6-month-old infant is brought to the emergency department after experiencing vomiting and diarrhea for 4 days. Which prescription from the health care provider is the priority? Click on the exhibit button for additional information.

Assessment Date 

• Temperature : 100.4 F (38 C)
• Heart rate : 168/min
• Respirations : 68 / min
• Capillary refill time : 4 seconds

IV ondansetron 2 mg every 8 hours

IV acetaminophen 60 mg every 6 hours

IV ampicillin 240 mg every 12

IV normal saline bolus 20 mL/kg over 1 hour

Infants and young children have a higher percentage of body water than older children and adults. As a result, they become dehydrated quickly due to fluid losses caused by vomiting and diarrhea. Signs of severe dehydration include lethargy, sunken fontanel, increased capillary refill time, increased heart rate, and increased respiratory rate. When dehydration is severe enough to affect the client's hemodynamic status or to potentiate shock, the priority is intravenous rehydration (Option 3).

(Option 1) A temperature of 100.4 F (38 C) is a mild fever in an infant and may indicate the need for acetaminophen. However, hydration of the infant takes priority over this action.

(Option 2) Antibiotics may be indicated due to the infant's increased temperature. The fluid bolus is of higher priority, as restoration of circulating volume is key in severe dehydration.

(Option 4) Ondansetron may be given to reduce nausea and vomiting after the infant is rehydrated intravenously, allowing for continued oral fluid replacement.

Educational objective: Severe dehydration occurs more rapidly in infants and young children due to a higher percentage of body water. Signs of severe dehydration include increased capillary refill time, increased heart rate, and increased respiratory rate. When severe dehydration occurs in an infant, the priority is intravenous rehydration.

Infants and young children have a higher percentage of body water than older children and adults. As a result, they become dehydrated quickly due to fluid losses caused by vomiting and diarrhea. Signs of severe dehydration include lethargy, sunken fontanel, increased capillary refill time, increased heart rate, and increased respiratory rate. When dehydration is severe enough to affect the client's hemodynamic status or to potentiate shock, the priority is intravenous rehydration (Option 3).

(Option 1) A temperature of 100.4 F (38 C) is a mild fever in an infant and may indicate the need for acetaminophen. However, hydration of the infant takes priority over this action.

(Option 2) Antibiotics may be indicated due to the infant's increased temperature. The fluid bolus is of higher priority, as restoration of circulating volume is key in severe dehydration.

(Option 4) Ondansetron may be given to reduce nausea and vomiting after the infant is rehydrated intravenously, allowing for continued oral fluid replacement.

Educational objective: Severe dehydration occurs more rapidly in infants and young children due to a higher percentage of body water. Signs of severe dehydration include increased capillary refill time, increased heart rate, and increased respiratory rate. When severe dehydration occurs in an infant, the priority is intravenous rehydration.

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