A nurse is reviewing the medical record of a 24-month-old child who has acute lymphocytic leukemia.Which of the following actions should the nurse take?
initiate bleeding precautions
place the child in knee-chest position
Apply viscous lidocaine to the oral mucosa
Obtain a rectal temperature every 4 hours .
The Correct Answer is A
Choice A rationale
Initiating bleeding precautions is an important action when caring for a child with acute lymphocytic leukemia. These patients are at increased risk of bleeding due to decreased platelet counts.
Choice B rationale
Placing the child in a knee-chest position is not typically necessary in the care of a child with acute lymphocytic leukemia.
Choice C rationale
Applying viscous lidocaine to the oral mucosa is not typically necessary in the care of a child with acute lymphocytic leukemia.
Choice D rationale
Obtaining a rectal temperature every 4 hours is not typically necessary in the care of a child with acute lymphocytic leukemia. However, regular monitoring of the child’s temperature is important to detect any signs of infection.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
An allergy to neomycin is a contraindication for receiving the measles, mumps, rubella (MMR) vaccine. Neomycin is an antibiotic that is used in some vaccines, including the MMR vaccine, to prevent bacterial contamination during the vaccine’s production. If a child has a known allergy to neomycin, they should not
receive the MMR vaccine because they could have a severe allergic reaction.
Choice B rationale
An upper respiratory infection 2 days ago is not a contraindication for receiving the MMR vaccine. While it’s generally recommended to wait until a child is healthy to give them a vaccine, a mild illness like a cold or upper respiratory infection usually isn’t a reason to delay vaccination.
Choice C rationale
A temperature of 37.2°C (99°F) is not a contraindication for receiving the MMR vaccine. This temperature is within the normal range and does not indicate a fever or illness that would prevent vaccination.
Choice D rationale
A family history of seizures is not a contraindication for receiving the MMR vaccine. While febrile seizures can occur in some children after receiving the MMR vaccine, they are rare and are not more likely to occur in children with a family history of seizures.
Correct Answer is D
Explanation
Choice A rationale
Applying a warm pack to the injection site prior to administration is not recommended as it does not effectively reduce pain during immunizations.
Choice B rationale
Asking the parent to leave the room during the injections is not recommended as it may increase the infant’s anxiety and distress.
Choice C rationale
Administering the injections in the deltoid muscle is not recommended for a 2-month-old infant. The recommended site for intramuscular administration of immunizations in children under 18 months of age is the vastus lateralis (anterolateral thigh)3.
Choice D rationale
Administering the injections while the infant is breastfeeding is recommended. Breastfeeding during immunizations has been shown to significantly reduce pain and distress in infants.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.