A client with hemophilia has a very swollen knee after falling from riding a bicycle. Which of the following should be the first nursing action?

Correct Answer: D

Rationale: The correct first nursing action is to apply an ice pack and compression dressings to the knee. This is to reduce swelling and control bleeding in the affected area, which is crucial for a client with hemophilia. Initiating an IV site for cryoprecipitate or type and cross-matching for transfusion may be necessary later, but the priority is to manage the immediate swelling and bleeding. Monitoring vital signs can wait until the initial intervention of addressing the knee swelling is done. This choice helps stabilize the client's condition and prevent further complications.

Correct Answer: B

Rationale: The priority nursing diagnosis for a client with DIC experiencing decreased oxygen saturation is Impaired Gas Exchange (B). This is because impaired gas exchange directly affects oxygenation, which is crucial for tissue perfusion and overall patient well-being. Addressing gas exchange will help improve oxygen saturation levels and prevent further complications. Pain (A) is important but not the priority in this case. Ineffective Tissue Perfusion (C) is related but secondary to impaired gas exchange. Anxiety (D) is also important but addressing oxygenation takes precedence for immediate patient safety.

Correct Answer: C

Rationale: The correct answer is C: Absolute neutrophil count (ANC). Neutrophils are a type of white blood cell that plays a crucial role in fighting infections. Chemotherapy can suppress the bone marrow, leading to a decrease in neutrophil count, putting the child at risk for infections. Monitoring ANC before chemotherapy helps determine the child's infection-fighting capability. A: Hemoglobin - Measures oxygen-carrying capacity of red blood cells, not directly related to infection-fighting capability. B: Red-blood-cell count - Measures the number of red blood cells, not directly related to infection-fighting capability. D: Platelets - Important for blood clotting, not directly related to infection-fighting capability.

Correct Answer: B

Rationale: The correct answer is B: Monitor for hematuria. Rhabdomyosarcoma is a type of cancer that originates from muscle tissue and can potentially lead to bleeding in the urine (hematuria). Monitoring for hematuria is crucial to assess the child's condition and detect any signs of complications. A: Positioning the child with the head elevated is not directly related to managing rhabdomyosarcoma. C: Demonstrating the use of a conformer is not relevant to the immediate nursing care for rhabdomyosarcoma. D: Administering oxygen may be necessary in some cases, but monitoring for hematuria is more specific and directly related to the potential complications of rhabdomyosarcoma.

Correct Answer: B

Rationale: The correct answer is B: Excess Fluid Volume Related to Decreased Plasma Filtration. In acute glomerulonephritis, the glomeruli are inflamed, leading to decreased filtration of plasma and retention of fluid. This results in excess fluid volume. This nursing diagnosis addresses the specific physiological issue of fluid retention in this condition. A: Risk for Urinary Tract Injury is not directly related to acute glomerulonephritis but rather to other factors such as urinary obstruction or trauma. C: Risk for Infection is not the priority nursing diagnosis in acute glomerulonephritis. Hypertension is a common complication, but infection risk is not directly related to the condition. D: Disturbed Personal Identity is not a relevant nursing diagnosis in this case as it does not address the physiological issue of fluid volume excess.