Nursing care of a child who is immunosuppressed due to leukemia or chemotherapeutic agents should include:
(choose one best answer)
Have them share a room with a child with active mumps
Restrict oral fluids
Strict isolation
Use good handwashing
The Correct Answer is D
Choice A reason: This choice is incorrect because having them share a room with a child with active mumps may expose them to infection and worsen their condition. A child who is immunosuppressed due to leukemia or chemotherapeutic agents has a weakened immune system and is more susceptible to infections from bacteria, viruses, fungi, or parasites. Therefore, they should be placed in a private room or cohorted with another immunosuppressed child.
Choice B reason: This choice is incorrect because restricting oral fluids may cause dehydration and electrolyte imbalance in the child who is immunosuppressed due to leukemia or chemotherapeutic agents. A child who is immunosuppressed due to leukemia or chemotherapeutic agents may have increased fluid losses from vomiting, diarrhea, fever, or sweating. Therefore, they should be encouraged to drink adequate fluids to maintain hydration and electrolyte balance.
Choice C reason: This choice is incorrect because strict isolation may cause psychological distress and social isolation in the child who is immunosuppressed due to leukemia or chemotherapeutic agents. A child who is immunosuppressed due to leukemia or chemotherapeutic agents may benefit from protective isolation, which involves using standard precautions and additional measures such as wearing gloves, gowns, masks, or eye protection when in contact with the child or their body fluids. However, strict isolation, which involves limiting visitors and activities, may harm the child's emotional and developmental well-being.
Choice D reason: This choice is correct because using good handwashing is essential nursing care for a child who is immunosuppressed due to leukemia or chemotherapeutic agents. Handwashing is the most effective way to prevent the transmission of microorganisms that can cause infections. The nurse should wash their hands before and after touching the child or their belongings, and teach the child and their family members to do the same. The nurse should also use alcohol-based hand rubs when water and soap are not available.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A: Cranberry juice is not a suitable fluid item to offer the child at this time, as it is acidic and can irritate the throat and cause pain or bleeding. Cranberry juice can also stain the surgical site and make it difficult to assess for signs of hemorrhage.
Choice B: Crushed ice is a suitable fluid item to offer the child at this time, as it is cold and can soothe the throat and
reduce swelling or inflammation. Crushed ice can also hydrate the child and prevent dehydration.
Choice C: Orange juice is not a suitable fluid item to offer the child at this time, as it is acidic and can irritate the throat and cause pain or bleeding. Orange juice can also interfere with the clotting process and increase the risk of hemorrhage.
Choice D: A strawberry milkshake is not a suitable fluid item to offer the child at this time, as it contains dairy products and can increase mucus production and cause coughing or gagging. A strawberry milkshake can also stain the surgical site and make it difficult to assess for signs of hemorrhage.
Correct Answer is D
Explanation
Choice A: Irregular respiratory rate is not a reliable indicator of mild dehydration, as it can be affected by many factors such as fever, infection, pain, or anxiety. An irregular respiratory rate can also indicate more severe dehydration or shock, which requires immediate intervention.
Choice B: Good skin integrity is not a reliable indicator of mild dehydration, as it can be maintained even in moderate dehydration. Good skin integrity does not reflect the fluid status of the body, as skin turgor and elasticity depend on other factors such as age, nutrition, and hydration.
Choice C: Blood pressure elevation is not a reliable indicator of mild dehydration, as it can be caused by other conditions such as stress, anxiety, pain, or hypertension. Blood pressure elevation can also indicate more severe dehydration or shock, which requires immediate intervention.
Choice D: Body weight is the most reliable indicator of mild dehydration, as it reflects the fluid loss or gain of the body. A loss of 5% or more of body weight indicates mild dehydration in infants. Body weight should be measured daily and compared with the baseline weight to monitor the fluid status of the infant.
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