The nurse analyzes the laboratory values of a pediatric client with leukemia who is receiving chemotherapy. The nurse notes the following lab values: platelets 19,500/mcl (nl. 140,000-400,000/mcL), hemoglobin 11 g/dL (nl. 12-16 g/dL), white blood cell count 9,800/mcl (nl. 5,000-10,000/mcL). Based on these findings, which intervention should the nurse prioritize in the plan of care?
Monitoring closely for signs of infection.
Transfusing packed red blood cells.
Administering intravenous immunoglobulins.
Initiating bleeding precautions.
The Correct Answer is D
A. Monitoring for infection is important, but the white blood cell count is within normal limits, so it is not the immediate priority.
B. Although the hemoglobin is slightly low, it is not critically low, so transfusion of packed red blood cells is not immediately necessary.
C. Intravenous immunoglobulins are not indicated based on the current lab values.
D. The platelet count is critically low, placing the client at high risk for bleeding. Initiating bleeding precautions is the priority to prevent hemorrhage.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Neurologic function is not typically affected by nephrotic syndrome, so improvement in this area is not an indicator of recovery.
B. Weight gain might indicate fluid retention rather than recovery in nephrotic syndrome.
C. The absence of protein in the urine indicates that the kidneys are functioning properly and that the syndrome is resolving. Proteinuria is a hallmark of nephrotic syndrome, so its resolution is a key sign of recovery.
D. A negative gram stain is more relevant to infections, not nephrotic syndrome.
Correct Answer is B
Explanation
A. While newborns need to feed frequently, particularly breastfed infants, parents do not need to wake their baby for every feeding unless advised by their healthcare provider due to specific concerns like low birth weight.
B. After birth, the newborn receives initial vaccinations, such as the hepatitis B vaccine. The next set of vaccinations is typically administered at the 1 or 2-month check-up, so no additional immunizations are needed immediately after discharge.
C. Full head control is generally achieved by around 4 months of age, not 1 month.
D. Babies typically triple their birth weight by around 12 months of age, not by 4-6 months.
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