A nurse is reviewing the laboratory values of an eight-month-old infant who is newly diagnosed with leukemia. Their most recent platelet count is 120,000/mm3 (200,000 to 475,000/mm3). Which of the following provider prescriptions should the nurse anticipate?
Administer packed red blood cells transfusion (PRBC)
Avoid taking rectal temperatures
Place child in protective environment precautions
Swab the oral cavity with viscous lidocaine
The Correct Answer is B
A. Administer packed red blood cells transfusion (PRBC):
While anemia may also be a concern in leukemia, the primary issue here is thrombocytopenia, not anemia. Administering packed red blood cells transfusion would address anemia, not the low platelet count.
B. Avoid taking rectal temperatures:
This is the correct option. Taking rectal temperatures carries the risk of causing bleeding or trauma, especially in individuals with thrombocytopenia. It is essential to avoid invasive procedures or activities that may increase the risk of bleeding in a patient with a low platelet count.
C. Place child in protective environment precautions:
Protective environment precautions, also known as reverse isolation, are typically implemented for patients who are immunocompromised to protect them from exposure to infectious agents. While patients with leukemia may be immunocompromised, the low platelet count is the primary concern here, not infection risk.
D. Swab the oral cavity with viscous lidocaine:
Swabbing the oral cavity with viscous lidocaine is not indicated for thrombocytopenia. Lidocaine may have local anesthetic properties but does not address the underlying issue of low platelet count.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Polyuria
Polyuria, or excessive urination, is not typically associated with intussusception. This symptom is more commonly seen in conditions affecting the kidneys or urinary tract.
B. Scaphoid abdomen
A scaphoid abdomen refers to a concave or hollowed appearance of the abdomen, which is not typically observed in intussusception. In intussusception, abdominal distension and tenderness are more common findings.
C. Gelatinous red stool
Gelatinous red stool, often described as "currant jelly" stool, is a classic manifestation of intussusception. It occurs due to the mixture of blood, mucus, and bowel contents.
D. Generalized edema
Generalized edema, or swelling throughout the body, is not a typical manifestation of intussusception. It is more commonly associated with conditions such as heart failure or kidney disease.

Correct Answer is C
Explanation
A. Increased respiratory rate: An increased respiratory rate may indicate that the child is experiencing respiratory distress or discomfort, which could be a sign that suctioning was not effective or that it was too aggressive. Ideally, after suctioning, the child's respiratory rate should stabilize or decrease as they are able to breathe more comfortably with a clear airway.
B. Decreased oxygen saturation: A decreased oxygen saturation level may indicate that the child is not receiving enough oxygen, which could be a sign of ineffective suctioning or airway obstruction. Effective suctioning should improve oxygenation by removing secretions and allowing for better airflow. A decrease in oxygen saturation would suggest the need for further assessment and intervention.
C. Clear breath sounds: This is the correct option. Clear breath sounds indicate that the airway has been effectively cleared of excess secretions, allowing for clear airflow. After suctioning, the nurse should listen for clear breath sounds without any crackles, wheezes, or other abnormal sounds indicating obstruction or congestion.
D. Increased oral secretions: Increased oral secretions may suggest that suctioning was not effective in clearing secretions from the airway, leading to pooling of secretions in the mouth. Effective suctioning should remove excess secretions from the airway, reducing the need for excessive oral secretions.
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