A nurse is reviewing the medical record of a 24-month-old child who has acute lymphocytic leukemia.Which of the following actions should the nurse take?
initiate bleeding precautions
place the child in knee-chest position
Apply viscous lidocaine to the oral mucosa
Obtain a rectal temperature every 4 hours .
The Correct Answer is A
Choice A rationale
Initiating bleeding precautions is an important action when caring for a child with acute lymphocytic leukemia. These patients are at increased risk of bleeding due to decreased platelet counts.
Choice B rationale
Placing the child in a knee-chest position is not typically necessary in the care of a child with acute lymphocytic leukemia.
Choice C rationale
Applying viscous lidocaine to the oral mucosa is not typically necessary in the care of a child with acute lymphocytic leukemia.
Choice D rationale
Obtaining a rectal temperature every 4 hours is not typically necessary in the care of a child with acute lymphocytic leukemia. However, regular monitoring of the child’s temperature is important to detect any signs of infection.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
When prioritizing care for multiple clients, the nurse should first assess the client who is most unstable and has the most urgent needs. In this case, the adolescent with sickle cell anemia and slurred speech should be assessed first. Slurred speech could indicate a stroke, which is a life-threatening condition that requires immediate medical attention. The other clients, while they also require care, are not in immediate danger and can be assessed after the adolescent with sickle cell anemia.
Correct Answer is C
Explanation
Choice A rationale
Pinpoint pupils are not a typical finding in an adolescent who has inhaled gasoline. Pinpoint pupils are more commonly associated with opioid use.
Choice B rationale
Hypothermia is not a typical finding in an adolescent who has inhaled gasoline. Inhalation of gasoline can cause central nervous system depression, leading to symptoms such as dizziness, confusion, and ataxia.
Choice C rationale
Ataxia, or lack of muscle coordination, can occur after inhaling gasoline. The gasoline vapors can depress the central nervous system, leading to symptoms such as dizziness, confusion, and ataxia.
Choice D rationale
Hyperactive reflexes are not a typical finding in an adolescent who has inhaled gasoline. Inhalation of gasoline can cause central nervous system depression, leading to symptoms such as dizziness, confusion, and ataxia.
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