On admission, a child with leukemia has widespread purpura and a platelet count of 19,000/mm3. What is the priority nursing intervention?
Assessing neurological status
Monitoring vital signs during platelet transfusions
Providing family education about how to prevent bleeding
Inserting an intravenous line
The Correct Answer is A
A. Assessing neurological status: A critically low platelet count (<20,000/mm³) puts the child at risk for intracranial hemorrhage. Assessing for changes in mental status, pupil reaction, or headache is the priority.
B. Monitoring vital signs during platelet transfusions: Important, but not the first or priority intervention.
C. Providing family education about how to prevent bleeding: Education is important, but not priority in a critical situation.
D. Inserting an intravenous line: IV access is useful but is not the first action to prevent life-threatening complications like bleeding into the brain.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Peripheral neuropathy: Some chemotherapy drugs (e.g., vincristine) can cause neuropathy of the bowel, leading to constipation and abdominal distention.
B. Myelosuppression: This refers to bone marrow suppression, leading to anemia, neutropenia, and thrombocytopenia-not directly associated with bowel function.
C. Stomatitis: Inflammation of the mouth mucosa; causes oral pain and ulcers, but not abdominal symptoms.
D. Hemorrhage: Would present with signs like bruising or bleeding, not firm abdomen and constipation.
Correct Answer is ["3.8"]
Explanation
Convert weight: 22 lb ÷ 2.2 = 10 kg
Total daily dose: 1.5 mg/kg × 10 kg = 15 mg/day
Divided every 6 hr = 4 doses/day → 15 mg ÷ 4 = 3.75 mg/dose
1 mg/mL solution → 3.75 mg = 3.8 mL (rounded to nearest tenth)
Correct answer: 3.8 mL per dose
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