Nursing 4516 Questions prioritation and delegation

Questions prioritation and delegation Question 1 See full question 4m 1s A child with hemophilia is hospitalized with bleeding into the knee. Which action should the nurse take first? You Selected:  Elevate the affected part Correct response:  Elevate the affected part Explanation: Bleeding into the joint is the most common type of bleeding episode in the more severe forms of hemophilia. Elevating the affected part and applying pressure and cold are indicated. The nurse should anticipate transfusing the missing clotting factor rather than whole blood or plasma, which won’t stop the bleeding promptly, and may pose a risk of fluid overload. Active ROM exercises are contraindicated because they may cause more bleeding, injury, and pain. Question 2 See full question 10s A client has a respiratory rate of 4 breaths/min. What are this nurse’s priority assessments? You Selected:  Level of consciousness and a pulse oximetry value Correct response:  Level of consciousness and a pulse oximetry value Explanation: This nurse should first attempt to rouse the client to increase the respiratory rate. Pulse oximetry and breath sounds should be assessed, and the provider informed of the findings. An ABG analysis may be ordered to determine specific carbon dioxide and oxygen levels, which would indicate the effectiveness of ventilation. An assessment of reflexes and heart sounds would be part of the more extensive examination done after the respiratory rate has stabilized. . Question 3 See full question 1m 18s Immediately after birth, a nurse assesses the neonate’s respiratory effort as slow. The neonate is actively moving but grimaces in response to stimulation. His fingers and toes are bluish, and his heart rate is 130 bpm. Which step should the nurse take next? You Selected:  Wrap the infant in a warm blanket Correct response:  Provide oxygen and stimulate the baby to cry Explanation: The nurse should stimulate the baby to cry, provide oxygen, and call the provider to evaluate reflex irritability. It would be inappropriate to tell the provider that the neonate appears abnormal. The neonate’s Apgar score is 7. Of a maximum possible Apgar score of 10, the nurse deducts one point for acrocyanosis, one point for slow respiratory effort, and one point for the grimace. Although keeping the infant warm is important, the infant clearly needs more aggressive interventions such as oxygen and stimulation