A child with hemophilia arrives at the clinic with a swollen knee after falling off a bicycle. Which action should the nurse implement first?
Type and cross for possible transfusion.
Initiate an IV site and begin infusing normal saline.
Monitor the child's vital signs frequently.
Apply ice pack and compression dressing to knee.
The Correct Answer is D
Choice A rationale
Typing and crossmatching for a possible transfusion is not the immediate priority for a child with hemophilia who has a swollen knee. While a transfusion might be necessary if there is significant bleeding, initial management should focus on controlling the bleeding and minimizing joint damage.
Choice B rationale
Initiating an IV site and beginning infusing normal saline is not the first action to take in this scenario. While IV access might be needed later, immediate measures should focus on controlling bleeding and reducing swelling to prevent further damage to the knee joint.
Choice C rationale
Monitoring the child's vital signs frequently is important, but it is not the first action to take. The priority is to control the bleeding and reduce the swelling, which are the immediate concerns in this situation.
Choice D rationale
Applying an ice pack and compression dressing to the knee is the first action to take. This helps to control bleeding, reduce swelling, and minimize joint damage. This is a crucial step in managing hemophilia-related injuries and should be done immediately upon recognizing a swollen joint.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["1500"]
Explanation
Step 1 is. (500 mL ÷ 20 min) × 60 min/hr = 1500 mL/hr. Answer: 1500 mL/hr.
Correct Answer is B
Explanation
Choice A rationale
Encouraging the child to dress in clothing that suits her sexual maturity level is not an appropriate approach for managing precocious puberty. The goal of treatment with LHRH is to delay further development until the appropriate age, allowing the child to dress according to her chronological age rather than her advanced physical maturity.
Choice B rationale
The purpose of LHRH therapy is to regulate and normalize the child's hormonal levels, which can slow or stop the progression of precocious puberty. As the therapy takes effect, differences in sexual maturity between the child and her peers should diminish over time, allowing her development to align more closely with her age group.
Choice C rationale
LHRH treatment for precocious puberty is typically not lifelong. It is used to delay puberty until a more appropriate age. Once treatment is stopped, the child's body will resume normal pubertal development. Parents should understand that the therapy is temporary and aimed at managing early onset puberty.
Choice D rationale
Starting the child on birth control pills is not a standard treatment for precocious puberty. The goal of LHRH therapy is to manage hormonal levels to delay puberty, not to prevent pregnancy. Birth control pills are not necessary and do not address the underlying condition being treated with LHRH therapy. .
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