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 D
Explanation
A. Initiate an infusion of IV fluids:
Administering IV fluids may be necessary to maintain hydration and support circulation, but it is not the first action to take in managing status asthmaticus. In this acute situation, the priority is to address airway obstruction and respiratory distress.
B. Obtain a blood specimen for ABG analysis:
Obtaining arterial blood gas (ABG) analysis can provide valuable information about the child's respiratory status, including oxygenation and acid-base balance. However, it is not the first action to take in managing status asthmaticus.
C. Administer a dose of an IV corticosteroid:
Administering systemic corticosteroids (such as IV hydrocortisone or methylprednisolone) is a crucial intervention in managing status asthmaticus to reduce airway inflammation and improve respiratory function. However, it is not the first action to take.
D. Apply humidified oxygen:
This is the correct action to take first. Applying humidified oxygen helps improve oxygenation and relieve bronchospasm by providing supplemental oxygen to the child's lungs. Oxygen therapy is essential in managing respiratory distress associated with status asthmaticus and should be initiated promptly.
Correct Answer is D
Explanation
A. FACES: The FACES pain scale is a visual analog scale commonly used with older children who can point to or select a facial expression that best represents their pain level. It may not be suitable for infants who may not have the cognitive or motor skills to use the scale effectively.
B. COMFORT: The COMFORT scale assesses pain in infants and young children based on behaviors such as crying, facial expressions, and body movements. It evaluates parameters such as alertness, calmness, respiratory response, physical movement, and muscle tone. The COMFORT scale is suitable for assessing pain in infants and young children, including those who are postoperative.
C. CRIES: The CRIES scale is a neonatal pain assessment tool that evaluates crying, oxygen saturation, vital signs, expression, and sleeplessness. While it is designed for newborns and infants up to 6 months of age, it may not be as appropriate for a 12-month-old infant who is postoperative and beyond the neonatal period.
D. FLACC: The FLACC scale assesses pain in infants and young children based on five behavioral categories: facial expression, leg movement, activity level, cry, and consolability. It is commonly used in pediatric settings and is suitable for assessing pain in infants who are postoperative.
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