A nurse is planning care for a child who has neutropenia due to leukemia. Which of the following interventions should the nurse include in the plan of care?

Screen the child's visitors for active infections.

Prepare the child for a platelet transfusion.

Monitor the child for indications of active bleeding.

Initiate a low-protein diet for the child.

Answer and Explanation

The Correct Answer is A

A. Screen the child's visitors for active infections. Neutropenia places the child at high risk for infection due to a severely weakened immune system. Screening visitors for signs of illness is essential to minimize exposure to infectious agents.
B. Prepare the child for a platelet transfusion. Platelet transfusions are used to treat thrombocytopenia, not neutropenia. While leukemia may cause both conditions, neutropenia specifically increases infection risk, not bleeding risk.
C. Monitor the child for indications of active bleeding. While bleeding is a concern in leukemia, it is more directly linked to low platelet levels. The priority intervention for neutropenia is infection prevention, not bleeding control.
D. Initiate a low-protein diet for the child. A low-protein diet is not appropriate for a child with leukemia. These children need adequate protein for healing, immune support, and maintaining strength during treatment.

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Correct Answer is C

Explanation

A. Widening pulse pressure. This is typically associated with conditions like increased intracranial pressure or severe aortic regurgitation, not cardiac tamponade. Tamponade usually results in narrowed pulse pressure.
B. Coarse lung sounds. These may indicate fluid overload or pulmonary congestion, but they are not specific to cardiac tamponade and occur later or in different conditions.
C. Muffled heart sounds. This is a classic early sign of cardiac tamponade, caused by fluid accumulation in the pericardial sac, which dampens heart sounds on auscultation. It is part of Beck’s triad (muffled heart sounds, hypotension, and jugular vein distention).
D. Decreased jugular vein distention. In cardiac tamponade, jugular vein distention increases due to impaired venous return to the heart. Decreased JVD would be an unexpected finding in this condition.

A. "You can add honey to sweeten vegetables if they do not like them." B. "Raw carrots are a good snack to provide and can help with teething." C. "You can mash canned vegetables instead of purchasing baby food." D. "Introduce one new food every 3 to 5 days when starting solid foods"

Correct Answer is D

Explanation

A. "You can add honey to sweeten vegetables if they do not like them." Honey should be avoided in infants under 12 months due to the risk of infant botulism, a serious and potentially fatal illness caused by Clostridium botulinum spores.
B. "Raw carrots are a good snack to provide and can help with teething." Raw carrots pose a choking hazard for infants and should not be given in solid form. Teething rings or soft, age-appropriate snacks are safer alternatives for teething relief.
C. "You can mash canned vegetables instead of purchasing baby food." Canned vegetables often contain added sodium, which is not recommended for infants. Fresh or frozen vegetables without added salt are a safer option when preparing homemade baby food.
D. "Introduce one new food every 3 to 5 days when starting solid foods." This approach allows the caregiver to monitor for allergic reactions or food sensitivities. Introducing foods gradually helps identify the cause of any adverse response and promotes safe dietary progression.

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A nurse is planning care for a child who has neutropenia due to leukemia. Which of the following interventions should the nurse include in the plan of care?

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Naxlex Comprehensive Predictor Exams

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