A nurse is planning care for a 4-year-old child who has leukemia and is receiving chemotherapy. The child has an absolute neutrophil count of 140/mm³. Which of the following interventions should the nurse include in the plan?
Administer the varicella vaccine to the child.
Increase the child's intake of fresh fruit.
Avoid taking the child's temperature rectally.
Restrict bathing to every other day.
The Correct Answer is C
Choice A reason: Administering the varicella vaccine to a child with leukemia and a low neutrophil count is not recommended because live vaccines are contraindicated due to the child's compromised immune system.
Choice B reason: Increasing the child's intake of fresh fruit is not advisable in this case because fresh fruits may carry bacteria that can cause infection in a child with a low neutrophil count.
Choice C reason: Avoiding rectal temperature measurements is important to prevent potential injury and infection in a child with a low neutrophil count, as their immune system is weakened.
Choice D reason: Restricting bathing to every other day is not necessary unless the child's skin is extremely sensitive due to chemotherapy. Regular bathing helps maintain hygiene and comfort.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: A gluten-free diet is essential for managing celiac disease, as gluten can trigger harmful immune responses in affected individuals. This diet excludes all forms of wheat, barley, rye, and oats unless they are labeled gluten-free.
Choice B reason: A high-fiber diet is generally healthy but is not specifically related to the management of celiac disease. During exacerbations, it is more important to ensure that all foods are gluten-free to avoid triggering symptoms.
Choice C reason: There is no need for a low-protein diet in celiac disease management. Protein is not related to the immune response triggered by gluten.
Choice D reason: Wheat flour contains gluten and must be avoided in a gluten-free diet. Alternative flours such as rice, corn, or gluten-free blends should be used instead.
Correct Answer is D
Explanation
Choice A reason: Contact precautions are used for infections that spread by direct or indirect contact with the patient or the patient's environment. While important, they are not the primary precaution for pertussis.
Choice B reason: Airborne precautions are used for diseases that are transmitted through the air over long distances, such as tuberculosis. Pertussis does not typically require airborne precautions.
Choice C reason: Protective precautions are used to protect immunocompromised patients from being infected by others. This is not applicable for a child with pertussis, who is the source of infection.
Choice D reason: Droplet precautions are used for diseases that are transmitted through large droplets expelled during coughing, sneezing, or talking. Pertussis, also known as whooping cough, is primarily spread through respiratory droplets, making droplet precautions the appropriate choice.
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