The nurse analyzes the laboratory values of a pediatric client with leukemia who is receiving chemotherapy. The nurse notes the following lab values: platelets 19,500/mcl (nl. 140,000-400,000/mcL), hemoglobin 11 g/dL (nl. 12-16 g/dL), white blood cell count 9,800/mcl (nl. 5,000-10,000/mcL). Based on these findings, which intervention should the nurse prioritize in the plan of care?
Monitoring closely for signs of infection.
Transfusing packed red blood cells.
Administering intravenous immunoglobulins.
Initiating bleeding precautions.
The Correct Answer is D
Rationale:
A. Monitoring for infection is important, but the white blood cell count is within normal limits, so it is not the immediate priority.
B. Although the hemoglobin is slightly low, it is not critically low, so transfusion of packed red blood cells is not immediately necessary.
C. Intravenous immunoglobulins are not indicated based on the current lab values.
D. The platelet count is critically low, placing the client at high risk for bleeding. Initiating bleeding precautions is the priority to prevent hemorrhage.
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View Related questions
Correct Answer is A
Explanation
Rationale:
A. Hypertension (blood pressure of 136/92 mm Hg) in a child with acute pyelonephritis can indicate a severe condition that may lead to renal damage or worsening kidney function. Immediate intervention is necessary to manage high blood pressure and prevent complications.
B. A heart rate of 100 bpm is within normal limits for a 7-year-old and does not require immediate action.
C. Decreased urine output is concerning and needs monitoring, but hypertension is the more urgent issue.
D. Tea-colored urine suggests hematuria or concentrated urine, which is important but not as immediately life-threatening as high blood pressure.
Correct Answer is D
Explanation
Rationale:
A. Applying topical diphenhydramine may help with local itching but is not the priority in a child with a known allergy to insect stings.
B. A cool pack can reduce swelling but is not the priority action if an allergic reaction is suspected.
C. Positioning the child with legs elevated is appropriate if there are signs of shock but does not address the immediate risk of airway compromise.
D. Assessing the client's airway and breathing rate is the priority because a child with a known allergy to insect stings is at risk for anaphylaxis, which can cause airway obstruction and respiratory distress. Early recognition and intervention are critical.