A nurse is creating a plan of care for a child who has acute lymphoid leukemia and an absolute neutrophil count of 400/mm³ (2500 to 8000/mm³). Which of the following interventions should the nurse include in the plan?

Encourage friends and family to visit the child.

Provide a low-protein diet for the child.

Collect a daily urine specimen from the child to check for proteinuria.

Withhold administering the varicella vaccine to the child.

Answer and Explanation

The Correct Answer is D

A. Encouraging friends and family to visit the child is not appropriate due to the risk of infections, as the child has a severely compromised immune system.

B. A low-protein diet is not indicated; children with leukemia often require adequate nutrition to support their health.

C. Collecting a daily urine specimen for proteinuria is not specifically indicated for this condition; the focus should be on infection prevention.

D. Withholding the varicella vaccine is essential because live vaccines are contraindicated in immunocompromised patients due to the risk of severe infections.

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Correct Answer is C

Explanation

A. Concerns about participation in team sports may indicate a desire for improved lung function but do not directly necessitate the use of a high-frequency chest compression vest.

B. Discomfort during nebulizer treatments may warrant alternative therapies, but it is not a direct indication for a high-frequency chest compression vest.

C. A small amount of mucus after percussion therapy suggests inadequate airway clearance, which may prompt the need for more effective techniques, such as the high-frequency chest compression vest, to facilitate mucus clearance and improve lung function.

D. A fever indicates a potential infection and requires further assessment but does not directly suggest the need for a high-frequency chest compression vest.

A. Have the client wear a surgical mask while being transported outside the room. B. Wear a surgical mask while providing care for the client. C. Restrict visitors from entering the client's room during hospitalization. D. Initiate contact precautions for the client upon admission.

Correct Answer is A

Explanation

A. Having the client wear a surgical mask while being transported outside the room is essential to prevent the transmission of TB to others. This minimizes exposure to airborne droplets.

B. Wearing a surgical mask while providing care for the client is not sufficient for preventing TB transmission; an N95 respirator is required to protect healthcare workers from inhaling airborne particles.

C. While restricting visitors may help limit exposure, it is not the most effective preventive measure compared to ensuring that the client wears a mask when out of their room.

D. Initiating contact precautions is not necessary for TB, as it primarily requires airborne precautions. Airborne isolation precautions should be followed, including the use of N95 respirators for healthcare workers and appropriate ventilation.

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A nurse is creating a plan of care for a child who has acute lymphoid leukemia and an absolute neutrophil count of 400/mm³ (2500 to 8000/mm³). Which of the following interventions should the nurse include in the plan?

Nursing Test Bank

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