A nurse is planning care for a 4-year-old child who has leukemia and is receiving chemotherapy. The child has an absolute neutrophil count of 140/mm³. Which of the following interventions should the nurse include in the plan?
Administer the varicella vaccine to the child.
Increase the child's intake of fresh fruit.
Avoid taking the child's temperature rectally.
Restrict bathing to every other day.
The Correct Answer is C
Choice A reason: Administering the varicella vaccine to a child with leukemia and a low neutrophil count is not recommended because live vaccines are contraindicated due to the child's compromised immune system.
Choice B reason: Increasing the child's intake of fresh fruit is not advisable in this case because fresh fruits may carry bacteria that can cause infection in a child with a low neutrophil count.
Choice C reason: Avoiding rectal temperature measurements is important to prevent potential injury and infection in a child with a low neutrophil count, as their immune system is weakened.
Choice D reason: Restricting bathing to every other day is not necessary unless the child's skin is extremely sensitive due to chemotherapy. Regular bathing helps maintain hygiene and comfort.
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Related Questions
Correct Answer is B
Explanation
Choice A reason: Asking the parent to leave the room during the injections is not recommended as the presence of a parent can provide comfort to the infant, which may help in reducing pain and anxiety.
Choice B reason: Administering the injections while the infant is breastfeeding is an effective method to decrease pain. Breastfeeding provides comfort and distraction, and the natural sugars in breast milk can have a mild analgesic effect.
Choice C reason: Applying a warm pack to the injection site prior to administration is not a standard practice for reducing pain from immunizations. Instead, using a cold compress after the injection can help to reduce swelling and discomfort.
Choice D reason: Administering injections in the deltoid muscle is not appropriate for a 2-month-old infant due to the underdeveloped muscle mass. The anterolateral thigh is the recommended site for immunizations in infants.
Correct Answer is C
Explanation
Choice A reason: Providing frequent range of motion to the neck and shoulders is not recommended for an infant with bacterial meningitis, as it could cause discomfort or pain due to the inflammation of the meninges.
Choice B reason: Keeping the television on to provide background noise is not advisable, as infants with meningitis may be sensitive to noise, and it could potentially increase their discomfort or agitation.
Choice C reason: Padding the siderails of the crib is important to ensure the safety of the infant. It helps to prevent injury if the infant has seizures, which can be a complication of meningitis.
Choice D reason: Placing the infant in a semi-private room is not a specific intervention for the care of an infant with bacterial meningitis. It is more important to focus on interventions that address the infant's immediate health needs.
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