A nurse is reinforcing teaching with the parents of a child who has hemophilia about the care of an injury that causes bleeding. Which of the following instructions should the nurse include in the teaching?
Perform passive range-of-motion to the affected area.
Apply an ice pack to the injury.
Position the injured extremity below the level of the heart.
Administer ibuprofen.
The Correct Answer is B
A. Performing passive range-of-motion exercises can cause further bleeding and should be avoided during an acute injury.
B. Applying an ice pack helps to constrict blood vessels, reduce bleeding, and minimize swelling, making it a recommended action for managing injuries in hemophilia.
C. Positioning the injured extremity below the level of the heart can increase blood flow to the area and worsen the bleeding.
D. Administering ibuprofen is not recommended as it can inhibit platelet function and increase the risk of bleeding. Acetaminophen is a safer alternative for pain relief in children with hemophilia.
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Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"C"}
Explanation
The nurse should clarify the child's prescription of dextrose 5% in 0.45% sodium chloride with 20 mEq potassium chloride/L at 75 mL/hr because of the child's laboratory values. The elevated potassium level of 6.2 mEq/L, which is above the normal range of 3.4 to 4.7 mEq/L, indicates hyperkalemia. Administering additional potassium could exacerbate this condition, therefore, it is crucial to review the prescription and adjust it accordingly to ensure the safety and well-being of the child.
Correct Answer is C
Explanation
A. Cleansing the surgical site is not typically recommended as it can interfere with healing and cause trauma to the area. The surgical site should be kept clean and dry according to the surgeon's instructions.
B. Placing the infant in a supine position is not recommended as it can increase the risk of aspiration and disrupt the surgical site. Positioning should be done to protect the surgical repair.
C. Applying elbow immobilizers to both arms prevents the infant from touching or putting their hands in their mouth, which helps to protect the surgical site from injury and allows it to heal properly.
D. Offering a pacifier with glucose syrup is not appropriate as sucking on a pacifier can disrupt the surgical site and glucose syrup is not necessary in this situation.
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