A nurse is caring for a child with leukemia. The nurse recognizes that the child is at increased risk for

Correct Answer: B

Rationale: In pediatric oncology, children with leukemia are at increased risk for infections due to compromised immune function from the disease itself and the treatment modalities such as chemotherapy. The correct answer is B) Infection. Leukemia affects the production of normal white blood cells, which are crucial for fighting infections. Children undergoing treatment for leukemia often experience neutropenia, a condition characterized by low levels of neutrophils, a type of white blood cell responsible for fighting bacterial and fungal infections. Option A) Hypoglycemia is not directly related to leukemia. While some chemotherapy drugs may cause alterations in blood sugar levels, it is not a primary concern for children with leukemia. Option C) Dehydration is not a common risk specifically associated with leukemia. Although some chemotherapy medications can cause side effects like nausea, vomiting, or diarrhea, leading to dehydration, it is not a direct consequence of leukemia itself. Option D) Cardiac arrhythmias are not a typical risk for children with leukemia. While certain chemotherapy drugs may have cardiotoxic effects, cardiac arrhythmias are not a primary concern in the immediate care of a child with leukemia. Understanding the increased susceptibility to infections in children with leukemia is crucial for nurses caring for these patients. Nurses need to monitor for signs of infection, practice strict infection control measures, and educate patients and families on the importance of preventing infections through good hygiene practices and avoiding exposure to sick individuals. This knowledge is vital for providing safe and effective care to pediatric patients with leukemia.

Correct Answer: B

Rationale: The correct answer is B) Rest and hydration. When a child is diagnosed with a viral upper respiratory infection, antibiotics are not effective because antibiotics only work against bacterial infections, not viral ones. Antiviral medications are specifically designed to treat viral infections, but they are not typically used for common upper respiratory infections in children. Corticosteroids may be used in certain cases to reduce inflammation, but they are not the primary treatment for viral upper respiratory infections. In an educational context, it is crucial for nurses to understand the appropriate treatments for different types of infections to provide safe and effective care to pediatric patients. Teaching parents and caregivers about the importance of rest and hydration in managing viral upper respiratory infections helps them support their child's recovery at home. Nurses play a vital role in patient education, promoting healthy behaviors, and ensuring families have the knowledge they need to care for their children during illness.

Correct Answer: C

Rationale: The correct answer is C) Assessing for other signs of infection. When a child presents with a fever, it is crucial to assess for other signs of infection to determine the underlying cause. Fever can be a symptom of various conditions, including infections. By assessing for other signs such as cough, runny nose, rash, or pain, the nurse can gather more information to guide further interventions and treatment. Option A) Administering acetaminophen to reduce fever is important to provide comfort to the child and help reduce fever-related symptoms. However, it is not the priority in this situation. The underlying cause of the fever needs to be identified first. Option B) Encouraging the child to drink fluids is a good practice to prevent dehydration, but it is not the priority when assessing a child with a fever. Dehydration can be a concern but should come after assessing for signs of infection. Option D) Monitoring the fever every hour is important in the ongoing care of the child, but initially, assessing for other signs of infection takes precedence to determine the appropriate course of action. In an educational context, prioritizing nursing interventions based on assessment findings is a fundamental skill in pediatric nursing. Understanding the hierarchy of needs and immediate concerns helps nurses provide efficient and effective care to pediatric patients. By focusing on assessing for signs of infection first, nurses can address the root cause of the fever and tailor their care accordingly.

Correct Answer: D

Rationale: In this scenario, the correct answer is D) Protecting the child from injury and maintaining airway patency. During a seizure, the nurse's priority is to ensure the safety of the child by preventing injury and maintaining a clear airway to support adequate oxygenation. This is crucial as seizures can lead to physical harm and compromised breathing, posing immediate threats to the child's well-being. Option A, administering a dose of antiepileptic medication, is important but not the priority during an active seizure. The focus should be on managing the acute situation first. Option B, restraint of the child to prevent injury, is not recommended as it can lead to further harm and is against the principles of providing safe and ethical care. Option C, positioning the child on their back to prevent aspiration, is also incorrect as placing a child on their back during a seizure can increase the risk of aspiration due to the potential obstruction of the airway by the tongue. Educationally, it is essential for nurses to prioritize interventions during emergencies such as seizures based on immediate threats to the patient's safety and physiological needs. By understanding the rationale behind prioritizing safety and airway management, nurses can provide effective and evidence-based care to pediatric patients experiencing seizures.

Correct Answer: C

Rationale: The correct answer is C) Clear mucus from the lungs. Rationale: Chest physiotherapy is a crucial part of the treatment plan for children with cystic fibrosis. This therapy involves various techniques such as percussion, vibration, and postural drainage to help loosen and clear the thick, sticky mucus that builds up in the lungs of individuals with cystic fibrosis. By clearing the mucus from the lungs, chest physiotherapy helps improve ventilation, reduce the risk of respiratory infections, and enhance overall lung function in these children. Option A) Improve the child's ability to breathe deeply is incorrect because while chest physiotherapy can indirectly help improve breathing by clearing the airways, its primary goal is to clear mucus rather than focusing on deep breathing techniques. Option B) Increase lung compliance is not the primary purpose of chest physiotherapy in cystic fibrosis. Lung compliance refers to the ability of the lungs to expand and contract, and while chest physiotherapy can help with lung function, its main aim in cystic fibrosis is mucus clearance. Option D) Strengthen the child's respiratory muscles is also not the main goal of chest physiotherapy in cystic fibrosis. While chest physiotherapy may provide some benefits to respiratory muscle strength, its primary focus is on clearing mucus from the lungs to improve respiratory function and prevent complications. Educational context: Understanding the rationale behind the use of chest physiotherapy in children with cystic fibrosis is essential for nurses and healthcare providers involved in the care of these patients. By educating parents about the importance of daily chest physiotherapy and its role in clearing mucus from the lungs, nurses can empower them to take an active role in managing their child's condition and promoting better respiratory health outcomes.