A nurse is reinforcing teaching with the guardians of a preschooler who has leukemia. The nurse should identify that which of the following educational topics is the priority to include?
Promoting nutrition
Preventing infections
Supporting psychological wellness
Managing mucosal ulcerations
The Correct Answer is B
A. Promoting nutrition: While nutrition is important, preventing infections is more urgent in a preschooler with leukemia. Leukemia and its treatments, such as chemotherapy, can significantly weaken the immune system, making the child more susceptible to infections.
B. Preventing infections: Preventing infections is critical for children with leukemia because their immune systems are compromised, either by the disease itself or by treatments like chemotherapy. Educating the guardians on how to prevent infections (e.g., hand hygiene, avoiding crowds, keeping the environment clean) is crucial to avoid serious complications.
C. Supporting psychological wellness: While psychological support is important, the priority for a preschooler with leukemia is to focus on preventing infections and ensuring their physical well-being, as infections can lead to severe consequences.
D. Managing mucosal ulcerations: Mucosal ulcerations can be a concern for children undergoing cancer treatment, but preventing infections is a more immediate and potentially life-saving priority. Once infections are controlled, mucosal ulcerations can also be addressed.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"A"},"F":{"answers":"A"}}
Explanation
- Maintain infant in supine position: Given the infant's respiratory distress, including labored breathing, retractions, and nasal flaring, placing the infant in a supine position could worsen respiratory difficulties. The infant should be kept upright or in a semi-Fowler’s position to promote optimal breathing.
- Prepare the infant for a chest x-ray: A chest x-ray is crucial to assess the infant’s respiratory status and potential cardiac issues to identify any underlying causes of the symptoms, such as pneumonia, wheezing, cough, and labored breathing.
- Maintain infant on continuous pulse oximetry: Continuous pulse oximetry is essential for monitoring the infant's oxygen saturation levels. The infant is already on supplemental oxygen, and continuous monitoring will ensure that the oxygen levels are maintained and help identify any worsening of the respiratory condition.
- Monitor intake and output: Given the infant's poor feeding (consuming only half a bottle in the past 24 hours), monitoring intake and output is crucial to assess hydration status and nutritional needs. Decreased intake and output can indicate dehydration or worsening of the infant's condition.
- Initiate a peripheral IV line: Due to the infant’s poor feeding and the possibility of dehydration, establishing a peripheral IV line will allow for proper hydration and the administration of fluids or medications, as necessary, for the infant’s condition.
- Offer small, frequent feedings: Offering small, frequent feedings is appropriate for an infant with respiratory distress and decreased appetite. This can reduce the risk of aspiration and help ensure the infant receives adequate nutrition despite the difficulty with feeding.
Correct Answer is B
Explanation
A. A blood pressure of 95/58 mm Hg can be within an acceptable range for an infant and is not typically a cause for concern in a 2-month-old.
B. A respiratory rate of 18/min is abnormally low for a 2-month-old infant. Infants normally have a respiratory rate of about 30–60/min, and a low rate may indicate respiratory depression or other serious issues that should be reported promptly.
C. A temperature of 37.4° C (99.3°F) is within the expected range for an infant and does not indicate fever.
D. A heart rate of 160/min is within the normal range for a young infant, especially when awake or active.
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