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. Blood pressure can fluctuate and may not accurately reflect fluid loss in an infant, especially in early stages of dehydration.
B. Respiratory rate may increase with distress but is not a direct indicator of fluid loss.
C. Skin integrity can show signs of dehydration, but it is not as definitive as changes in body weight.
D. Body weight is the most reliable indicator of fluid loss, as it reflects changes in fluid status directly and provides a clear measure for assessing hydration.
Correct Answer is D
Explanation
A. Back pain may occur but is not typically urgent unless severe; it’s important to monitor but not the priority.
B. Frequent nosebleeds can occur due to dry mucous membranes but are not the most critical symptom to report immediately.
C. Itching of the skin can be managed with moisturizers and does not represent a medical emergency.
D. Feelings of isolation and depression are serious side effects associated with isotretinoin and should be reported immediately due to the risk of self-harm or suicidal thoughts.
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