A child has been admitted to the pediatric unit. Her absolute neutrophil count is 225 and the child has been placed in neutropenic isolation. Which action by a nurse indicates that the nurse requires further education? (Select all that apply)
The nurse monitors the child's vital signs every 2 to 4 hours
The nurse carefully washes his/her hands before and after providing care
The child has been placed in a semi-private room
The nurse assesses the child for clinical signs of an infection
The Correct Answer is C
A. The nurse monitors the child's vital signs every 2 to 4 hours is appropriate. Regular monitoring of vital signs is important in children with neutropenia to detect early signs of infection or sepsis.
B. The nurse carefully washes his/her hands before and after providing care is appropriate. Hand hygiene is critical in preventing the transmission of infection, especially in neutropenic patients who are at high risk of infections.
C. The child has been placed in a semi-private room requires further education. A child with a neutrophil count of 225 is at significant risk of infection, and placing the child in a semi-private room increases the risk of exposure to pathogens. The child should be placed in a private room to minimize exposure to infectious agents.
D. The nurse assesses the child for clinical signs of an infection is appropriate. Vigilant monitoring for infection is essential in neutropenic patients, as they are more susceptible to infections.
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Related Questions
Correct Answer is B
Explanation
A. Hematuria (blood in the urine) can occur in some conditions, but it is not a primary complication of hemophilia. Hemophilia more commonly leads to bleeding into joints and muscles rather than the urinary tract.
B. Hemarthrosis (bleeding into the joints) is a common complication of hemophilia. It occurs due to the lack of clotting factors, which prevents normal blood clotting and allows bleeding into joints, causing pain, swelling, and long-term joint damage.
C. Hemoptysis (coughing up blood) is not a typical complication of hemophilia, though it can occur in various respiratory conditions, such as infections or lung issues.
D. Hematemesis (vomiting blood) is a serious condition but is not commonly associated with hemophilia. Hemophilia's major complications are related to joint and muscle bleeding.
Correct Answer is D
Explanation
A. Age of the child is important in determining the approach to treatment and potential outcomes, but the priority in planning treatment is addressing the extent of the disease, particularly whether it has spread. Age may influence treatment choices but is secondary to assessing metastasis.
B. Range of motion in the affected area is important in managing functional outcomes, especially for tumors that affect muscles or joints, but the highest priority when planning care is understanding the extent of the disease, specifically metastasis, before focusing on rehabilitation.
C. Health complications from the tumor are significant for symptom management and treatment planning, but the critical first step in treatment is determining the stage of the cancer and whether the tumor has spread. This information guides treatment decisions.
D. Whether or not the tumor has metastasized is the highest priority. The spread of the tumor (metastasis) directly impacts the treatment plan and prognosis, influencing decisions such as the need for systemic therapies (chemotherapy) in addition to local treatments like surgery or radiation.
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