A nurse is creating a plan of care for a child who has acute lymphoid leukemia and an absolute neutrophil count of 400/mm³ (2500 to 8000/mm³). Which of the following interventions should the nurse include in the plan?

Encourage friends and family to visit the child.

Provide a low-protein diet for the child.

Collect a daily urine specimen from the child to check for proteinuria.

Withhold administering the varicella vaccine to the child.

Answer and Explanation

The Correct Answer is D

A. Encouraging friends and family to visit the child is not appropriate due to the risk of infections, as the child has a severely compromised immune system.

B. A low-protein diet is not indicated; children with leukemia often require adequate nutrition to support their health.

C. Collecting a daily urine specimen for proteinuria is not specifically indicated for this condition; the focus should be on infection prevention.

D. Withholding the varicella vaccine is essential because live vaccines are contraindicated in immunocompromised patients due to the risk of severe infections.

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Correct Answer is B

Explanation

While a home health nurse visit is important, it is not an immediate safety concern for the client's discharge.

B. The need for assistance when transferring is critical information as it directly impacts the client's safety during discharge; the oncoming nurse must ensure proper support is arranged.

C. The fact that the client's partner will bring clothes is relevant but does not affect the immediate care of the client.

D. Encouragement for personal hygiene is important but is not as urgent as ensuring the client can safely transfer without risk of falls or injury.

A. Urine output 120 mL in 4 hr B. Systolic blood pressure 12 mm Hg lower than the preoperative level C. Audible stridor D. Normal sinus rhythm with an occasional premature ventricular contraction

Correct Answer is C

No explanation

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A nurse is creating a plan of care for a child who has acute lymphoid leukemia and an absolute neutrophil count of 400/mm³ (2500 to 8000/mm³). Which of the following interventions should the nurse include in the plan?

Nursing Test Bank

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Explanation

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