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 ["8"]
Explanation
To calculate the dosage of diphenhydramine (Benadryl) for the child, we first determine the total milligrams needed per dose by multiplying the child's weight in kilograms by the prescribed milligrams per kilogram. The child weighs 20 kg, so the calculation is 20 kg * 5 mg/kg, which equals 100 mg per dose. The medication is supplied at a concentration of 12.5 mg per 5 ml. To find out how many milliliters are needed to provide 100 mg, we set up a proportion: 12.5 mg/5 ml = 100 mg/x ml. Solving for x gives us x = (100 mg * 5 ml) / 12.5 mg, which equals 40 ml. Therefore, the nurse will administer 40 milliliters of the medication for one dose.
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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