A nurse is planning care for a child who has neutropenia due to leukemia. Which of the following interventions should the nurse include in the plan of care?
Screen the child's visitors for active infections.
Prepare the child for a platelet transfusion.
Monitor the child for indications of active bleeding.
Initiate a low-protein diet for the child.
The Correct Answer is A
A. Screen the child's visitors for active infections. Neutropenia places the child at high risk for infection due to a severely weakened immune system. Screening visitors for signs of illness is essential to minimize exposure to infectious agents.
B. Prepare the child for a platelet transfusion. Platelet transfusions are used to treat thrombocytopenia, not neutropenia. While leukemia may cause both conditions, neutropenia specifically increases infection risk, not bleeding risk.
C. Monitor the child for indications of active bleeding. While bleeding is a concern in leukemia, it is more directly linked to low platelet levels. The priority intervention for neutropenia is infection prevention, not bleeding control.
D. Initiate a low-protein diet for the child. A low-protein diet is not appropriate for a child with leukemia. These children need adequate protein for healing, immune support, and maintaining strength during treatment.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Place a small, folded blanket behind the baby's neck to provide support while in the car seat. Adding extra padding behind the infant’s neck is not recommended, as it can alter the positioning and compromise the safety design of the car seat. Only manufacturer-approved inserts should be used.
B. Anchor the car seat in a rear-facing position in the back seat of the vehicle. Infants under the age of 2 should always be placed in a rear-facing car seat in the back seat. This position offers the best protection for the infant’s head, neck, and spine in the event of a crash.
C. Ensure the water heater temperature is set to no more than 54° C (129.2° F). This temperature is too high and increases the risk of scalding. The recommended maximum temperature for a household water heater is 49° C (120° F) to ensure infant safety.
D. Cover the baby with a cotton blanket when they are asleep. Using loose bedding, including blankets, increases the risk of sudden infant death syndrome (SIDS). Instead, the infant should sleep in a wearable blanket or sleep sack on a firm mattress without soft items.
Correct Answer is A
Explanation
A. Beneficence. This principle refers to acting in the best interest of the client by promoting their well-being and providing comfort. Sitting with a grieving client to offer emotional support is an act of kindness and compassion, aligning with beneficence.
B. Autonomy. Autonomy involves respecting the client’s right to make decisions about their own care. While important, it is not the primary ethical principle demonstrated in this situation.
C. Fidelity. Fidelity refers to keeping promises and maintaining trust in the nurse-client relationship. While the nurse is being supportive, the act described does not specifically demonstrate the principle of fidelity.
D. Veracity. Veracity involves telling the truth and being honest with clients. It is not the relevant principle in this context, as the focus is on emotional support rather than the communication of factual information.
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