A nurse is admitting a child who has leukemia and a critically low platelet count. Which of the following precautions should the nurse initiate?
Neutropenic
Droplet
Bleeding
Contact
The Correct Answer is C
A. Neutropenic Precautions: Neutropenia refers to a low neutrophil count, a type of white blood cell responsible for fighting infections. While children with leukemia are at risk for neutropenia due to the disease and its treatment, the primary concern in this scenario is the critically low platelet count and the risk of bleeding. Neutropenic precautions focus on preventing infections.
B. Droplet Precautions: Droplet precautions are used when dealing with respiratory infections that are transmitted through respiratory droplets, such as coughing or sneezing. This is not the primary concern for a child with leukemia and a low platelet count, as the main risk is bleeding due to the low platelet count.
C. Bleeding Precautions: Leukemia, especially in a child with a critically low platelet count, puts the child at a high risk of bleeding. Platelets are essential for blood clotting, and when they are severely decreased, even minor injuries can lead to excessive bleeding. The nurse should take precautions to minimize the risk of bleeding. This includes avoiding invasive procedures, using a soft toothbrush, and ensuring that the child does not participate in activities that could result in injury.
D. Contact Precautions: Contact precautions are used to prevent the transmission of infectious diseases through direct contact. While a child with leukemia may have a weakened immune system and be at risk of infections, the primary concern in this case is the critically low platelet count and the risk of bleeding. Contact precautions are more relevant in cases of contagious diseases where physical contact could transmit the infection.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A.Altered level of consciousness and thready pulse.
In a child after heart surgery to correct Tetralogy of Fallot (TOF), a thready pulse and altered level of consciousness can be indicative of poor cardiac output. This may suggest that the heart is not effectively pumping blood to meet the body's needs.
B. Bounding pulses and mottled skin: Bounding pulses and mottled skin are not typical signs of decreased cardiac output. Bounding pulses are often associated with increased cardiac output.
C. Capillary refill of 2 seconds and blood pressure of 96/47 mmHg: A capillary refill of 2 seconds is within the normal range, and a blood pressure of 96/47 mmHg is reasonable for a child. These findings do not necessarily indicate poor cardiac output.
D. Extremities warm to the touch and pale skin: Warm extremities and pale skin are not typical signs of decreased cardiac output. Cold extremities and cyanosis may be more concerning signs.
Correct Answer is C
Explanation
A. Obtaining a throat culture and B. visualizing the epiglottis with a tongue depressor are not safe actions for the nurse to perform without appropriate medical equipment and expertise. These actions can trigger a sudden airway obstruction in a child with epiglottitis. The priority is to ensure airway patency and seek immediate medical assistance.
C. Place the child in an upright position.
Suspected epiglottitis is a medical emergency that can result in rapid airway obstruction. Placing the child in an upright position helps improve airflow by allowing the throat to open and reduces the risk of complete airway obstruction. It's important not to perform invasive procedures (such as throat culture or visualization of the epiglottis) without proper medical equipment and expertise, as these actions can lead to worsening airway obstruction.
D. Transporting the child to radiology for a throat x-ray is not appropriate in this situation, as it may delay necessary interventions to secure the airway.
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