A nurse is creating a plan of care for a child who has acute lymphoid leukemia and an absolute neutrophil count of 400/mm³ (2500 to 8000/mm³). Which of the following interventions should the nurse include in the plan?
Encourage friends and family to visit the child.
Provide a low-protein diet for the child.
Collect a daily urine specimen from the child to check for proteinuria.
Withhold administering the varicella vaccine to the child.
The Correct Answer is D
Rationale:
A. Encouraging friends and family to visit the child is not appropriate due to the risk of infections, as the child has a severely compromised immune system.
B. A low-protein diet is not indicated; children with leukemia often require adequate nutrition to support their health.
C. Collecting a daily urine specimen for proteinuria is not specifically indicated for this condition; the focus should be on infection prevention.
D. Withholding the varicella vaccine is essential because live vaccines are contraindicated in immunocompromised patients due to the risk of severe infections.
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Correct Answer is C
Explanation
Rationale:
A. Concerns about participation in team sports may indicate a desire for improved lung function but do not directly necessitate the use of a high-frequency chest compression vest.
B. Discomfort during nebulizer treatments may warrant alternative therapies, but it is not a direct indication for a high-frequency chest compression vest.
C. A small amount of mucus after percussion therapy suggests inadequate airway clearance, which may prompt the need for more effective techniques, such as the high-frequency chest compression vest, to facilitate mucus clearance and improve lung function.
D. A fever indicates a potential infection and requires further assessment but does not directly suggest the need for a high-frequency chest compression vest.
Correct Answer is B
Explanation
Rationale:
A. A quick inhalation is not the correct technique; the child should take a slow, deep breath in while pressing down on the inhaler to ensure effective medication delivery.
B. Taking the medication 15 minutes before playing sports allows time for the medication to take effect, making this the best choice.
C. The mouthpiece should be cleaned more frequently, typically after each use, to prevent buildup of medication and bacteria.
D. Waiting 10 seconds between inhalations is generally advised; however, the more important instruction here is the timing of medication before sports.