A nurse is admitting a child who has leukemia and a critically low platelet count. Which of the following precautions should the nurse initiate?
Neutropenic
Droplet
Bleeding
Contact
The Correct Answer is C
A. Neutropenic Precautions: Neutropenia refers to a low neutrophil count, a type of white blood cell responsible for fighting infections. While children with leukemia are at risk for neutropenia due to the disease and its treatment, the primary concern in this scenario is the critically low platelet count and the risk of bleeding. Neutropenic precautions focus on preventing infections.
B. Droplet Precautions: Droplet precautions are used when dealing with respiratory infections that are transmitted through respiratory droplets, such as coughing or sneezing. This is not the primary concern for a child with leukemia and a low platelet count, as the main risk is bleeding due to the low platelet count.
C. Bleeding Precautions: Leukemia, especially in a child with a critically low platelet count, puts the child at a high risk of bleeding. Platelets are essential for blood clotting, and when they are severely decreased, even minor injuries can lead to excessive bleeding. The nurse should take precautions to minimize the risk of bleeding. This includes avoiding invasive procedures, using a soft toothbrush, and ensuring that the child does not participate in activities that could result in injury.
D. Contact Precautions: Contact precautions are used to prevent the transmission of infectious diseases through direct contact. While a child with leukemia may have a weakened immune system and be at risk of infections, the primary concern in this case is the critically low platelet count and the risk of bleeding. Contact precautions are more relevant in cases of contagious diseases where physical contact could transmit the infection.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. "Palliative care focuses on the care of the client." - This statement is accurate. Palliative care is centered around providing comprehensive care that addresses the physical, emotional, social, and spiritual needs of the patient.
B. "Palliative care is an inter-professional approach to the delivery of care." - This statement is also accurate. Palliative care typically involves a team of healthcare professionals, including physicians, nurses, social workers, chaplains, and other specialists, who work collaboratively to provide holistic care.
C. "Palliative care is the same as hospice care." - This statement is incorrect. Palliative care and hospice care share similarities in that they both focus on improving the quality of life for patients with serious illnesses, but they are not the same. The key difference is that palliative care can be provided at any stage of a serious illness, even alongside curative treatments, while hospice care is typically provided when a patient has a terminal illness with a prognosis of six months or less to live.
D. "Palliative care includes symptom management in the cent" - This statement is accurate. Symptom management and relief of distressing symptoms are essential components of palliative care, with the goal of improving the patient's quality of life.
So, the statement in option C is incorrect, and the registered nurse should correct it by explaining the distinction between palliative care and hospice care to the client's family.
Correct Answer is A
Explanation
A.Altered level of consciousness and thready pulse.
In a child after heart surgery to correct Tetralogy of Fallot (TOF), a thready pulse and altered level of consciousness can be indicative of poor cardiac output. This may suggest that the heart is not effectively pumping blood to meet the body's needs.
B. Bounding pulses and mottled skin: Bounding pulses and mottled skin are not typical signs of decreased cardiac output. Bounding pulses are often associated with increased cardiac output.
C. Capillary refill of 2 seconds and blood pressure of 96/47 mmHg: A capillary refill of 2 seconds is within the normal range, and a blood pressure of 96/47 mmHg is reasonable for a child. These findings do not necessarily indicate poor cardiac output.
D. Extremities warm to the touch and pale skin: Warm extremities and pale skin are not typical signs of decreased cardiac output. Cold extremities and cyanosis may be more concerning signs.
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