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 D
Explanation
A. Cashews contain some iron but are not the highest source compared to red meat.
B. Oranges are high in vitamin C but low in iron; they can help with iron absorption when consumed with iron-rich foods.
C. Yogurt provides calcium and protein but is not a significant source of iron.
D. Red meat is an excellent source of heme iron, which is more easily absorbed by the body than non-heme iron found in plant foods.
Correct Answer is B
Explanation
A. Raising the head of the bed may help with respiratory effort but does not address the underlying issue of decreased responsiveness. Immediate assessment and intervention are necessary.
B. Notifying the healthcare provider is critical as the child’s decreased responsiveness and respiratory rate indicate a potential deterioration in condition that requires prompt medical evaluation.
C. While obtaining an oximeter reading can provide useful information about oxygenation, the priority is to notify the HCP about the change in the child's neurological status.
D. Implementing seizure precautions is important for a child with a brain tumor, but the immediate concern is the change in responsiveness, necessitating HCP notification first.
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