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.
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.
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