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 A
Explanation
Rationale:
A. This response validates the client's feelings and opens the door for further conversation without judgment, encouraging the client to express more of their thoughts.
B. While this statement acknowledges the client's feelings, it may seem dismissive or minimize the depth of the client's distress.
C. Telling the client that many people experience similar feelings can invalidate the uniqueness of their grief and may discourage them from sharing more.
D. Asking "Why" may sound accusatory and could make the client feel defensive or misunderstood.
Correct Answer is B
Explanation
Rationale:
A. Attaching the NG tube to low intermittent suction is not recommended during gastric lavage, as suctioning can remove the lavage solution before it has a chance to work effectively.
B. Instilling the lavage solution in volumes of 500 mL at a time is correct as it allows for effective cleansing of the stomach and can help to clear out any blood or debris present.
C. Chilled lavage solution should not be used; it is recommended to use room temperature or warmed solution to avoid discomfort and potential complications such as cramping.
D. While 0.9% sodium chloride is isotonic and can be used for irrigation, it is not typically the solution used for gastric lavage; water or a specific lavage solution is more appropriate.