A nurse is admitting a child who has sepsis and a critically low platelet count. Based on this information which of the following precautions should the nurse initiate?
Respiratory
Airborne
Bleeding
Contact
The Correct Answer is C
A. Respiratory precautions are necessary for preventing the spread of respiratory infections but are not specifically indicated here.
B. Airborne precautions are required for diseases transmitted through the air (e.g., TB), not relevant in this scenario.
C. Bleeding precautions should be initiated due to the critically low platelet count, as this increases the risk of bleeding complications. Nurses should be vigilant in monitoring for signs of bleeding and minimizing invasive procedures.
D. Contact precautions are important for preventing the spread of infections, but in this case, the primary concern is bleeding due to low platelet counts.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","E","F"]
Explanation
A. Cold compresses may not be appropriate in this case. In sickle cell crises, warmth is typically encouraged to promote circulation and reduce pain, whereas cold can constrict blood vessels and potentially worsen ischemia.
B. Bedrest is appropriate for this client to minimize energy expenditure and allow the body to focus on healing. Pain management is also a priority, and limiting activity can help manage pain levels.
C. While oxygen can be helpful in managing hypoxia, the client’s oxygen saturation is currently 96% on room air, indicating adequate oxygenation. Routine administration of oxygen is not indicated in this scenario.
D. In sickle cell disease, hydration is important to reduce blood viscosity and prevent crises. Therefore, the nurse should encourage adequate fluid intake unless contraindicated.
E. The client has a significantly low hemoglobin level (5 g/dL), which may necessitate a blood transfusion to improve oxygen-carrying capacity and treat anemia. Consent should be obtained as part of the preparation for this intervention.
F. Administering IV fluids is essential for rehydration and improving circulation, which can help alleviate pain and prevent further sickling of cells.
G. While passive range-of-motion exercises can be beneficial, they are generally not recommended during acute pain episodes as they may exacerbate discomfort and pain. The focus should be on pain management and rest.
Correct Answer is D
Explanation
A. Removing nits with a fine-tooth comb is a crucial step in managing head lice to prevent re-infestation.
B. Washing bedding and clothing in hot water or sealing non-washable items helps eliminate lice and nits from the environment.
C. Soaking combs and brushes in hot water with shampoo helps ensure that any lice or nits on the grooming tools are eradicated.
D. All of the provided options are appropriate measures for managing pediculosis capitis effectively.
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