A nurse in the emergency department is caring for a preschool-age child who has hemophilia A and sustained an abdominal trauma following a motor vehicle crash. Which of the following actions should the nurse take?

Select all that apply.

Assess for changes in level of consciousness.

Administer factor VIII.

Perform passive range of motion hourly.

Administer factor IX.

Apply a warming blanket over the child.

Answer and Explanation

Correct Answer : A,B

A. Assess for changes in level of consciousness. Abdominal trauma can lead to internal bleeding, which might increase intracranial pressure if bleeding occurs in the brain. Monitoring for neurological changes is essential.
B. Administer factor VIII. Hemophilia A results from factor VIII deficiency, and replacing it prevents further bleeding.
C. Perform passive range of motion hourly. Movement may exacerbate bleeding into the joints or injured tissues. Rest is essential during acute bleeding episodes.
D. Administer factor IX. Factor IX is used for hemophilia B, not hemophilia A.
E. Apply a warming blanket over the child. Hypothermia management may be necessary in some trauma cases, but there is no indication it is needed here based on the scenario provided.

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Correct Answer is A

Explanation

A. Initiate contact precautions: RSV is a highly contagious respiratory virus spread via droplets and direct contact. To prevent transmission to others, contact precautions should be initiated.
B. Perform chest percussion and postural drainage: While these techniques can be used in some respiratory conditions, they are not the first-line intervention for RSV.
C. Encourage clear liquids by mouth: While oral rehydration may be appropriate in some cases of mild dehydration, this infant is likely experiencing respiratory distress, and oral intake may be difficult. Intravenous fluids may be required, especially if the infant is having difficulty feeding.
D. Administer IV antibiotics: RSV is caused by a virus, not a bacterial infection, so antibiotics are not effective in treating the infection.

A. Administer IV antibiotics. B. Monitor vital signs. C. Encourage oral fluids. D. Initiate droplet precautions.

Correct Answer is D

Explanation

A. Administer IV antibiotics: While urgent, antibiotics can be administered after precautions are in place to ensure safety.
B. Monitor vital signs: Important but not the first action. Vital signs can be monitored after precautions are initiated.
C. Encourage oral fluids: Incorrect because IV fluids are usually required due to the severity of the illness and risk of shock.
D. Initiate droplet precautions. Protecting others from transmission is the highest priority in managing bacterial meningitis, a highly contagious condition.

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A nurse in the emergency department is caring for a preschool-age child who has hemophilia A and sustained an abdominal trauma following a motor vehicle crash. Which of the following actions should the nurse take? Select all that apply.

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A nurse in the emergency department is caring for a preschool-age child who has hemophilia A and sustained an abdominal trauma following a motor vehicle crash. Which of the following actions should the nurse take?

Select all that apply.