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.
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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Related Questions
Correct Answer is A
Explanation
A. Turn off oxygen sources. After ensuring the client is safe, the priority is to reduce the risk of fire spreading, and oxygen greatly increases flammability. Turning off oxygen is a critical safety measure to prevent rapid combustion.
B. Put out the fire with an extinguisher. While extinguishing the fire is important, it should only be attempted if safe to do so and after addressing immediate dangers, such as oxygen sources and client safety.
C. Close the fire doors on the unit. This is part of containment under the RACE protocol (Rescue, Alarm, Contain, Extinguish), but it is not the first priority after rescue when oxygen is actively feeding the fire.
D. Notify the facility operator. This step corresponds to the "Alarm" phase of RACE and is essential for initiating the emergency response. However, it follows immediately after ensuring client safety and environmental hazard reduction, like turning off oxygen.
Correct Answer is B
Explanation
A. Wear clothing with zippers instead of buttons. This may be helpful for caregivers or for promoting independence in dressing, but it does not directly enhance safety in the home for a client with Alzheimer’s disease.
B. Place locks at the tops of exterior doors. Clients with Alzheimer’s are at risk for wandering, especially in later stages. Placing locks at the tops of doors helps prevent elopement while still allowing caregivers to control access, thus enhancing home safety.
C. Replace the carpet with hardwood floors. Carpets can actually provide more traction and cushioning than hardwood, which may be slippery and increase the risk of falls. Removing carpet is not necessary and could reduce safety.
D. Encourage physical activity prior to bedtime. Physical activity is beneficial but should be scheduled earlier in the day, as exercise close to bedtime may increase stimulation and interfere with sleep, which is already often disrupted in Alzheimer’s clients.
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