Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is reviewing the complete blood count results for a child who is receiving treatment for acute lymphoblastic leukemia. Which of the following findings should indicate to the nurse that the treatment is having a therapeutic effect?
A. WBC count 15,000/mm3
WBC count 15,000/mm3 is elevated, which may indicate ongoing leukemia activity. It does not necessarily indicate a therapeutic effect.
B. RBC count 5/mm3
RBC count 5/mm3 is extremely low and indicates severe anemia. This finding suggests that the treatment may not be having the desired therapeutic effect.
C. Hemoglobin 6.8 g/dL
Hemoglobin 6.8 g/dL is very low and indicates severe anemia. This is a concerning finding and suggests that the treatment may not be effective.
D. Platelet count 98,000/mm3
This is the correct answer. A platelet count of 98,000/mm3 is within a range that is generally considered acceptable for a child receiving treatment for leukemia. While it is lower than normal, it is not severely low and suggests that the treatment may be having a therapeutic effect.
This question is an excerpt from Nurse Dive's nursing test bank - RN Nursing Care of Children 2019 with NGN Proctored Exam. Take the full exam now
Full Explanation
A. WBC count 15,000/mm3 is elevated, which may indicate ongoing leukemia activity. It does not necessarily indicate a therapeutic effect.
B. RBC count 5/mm3 is extremely low and indicates severe anemia. This finding suggests that the treatment may not be having the desired therapeutic effect.
C. Hemoglobin 6.8 g/dL is very low and indicates severe anemia. This is a concerning finding and suggests that the treatment may not be effective.
D. This is the correct answer. A platelet count of 98,000/mm3 is within a range that is generally considered acceptable for a child receiving treatment for leukemia. While it is lower than normal, it is not severely low and suggests that the treatment may be having a therapeutic effect.
Similar Questions
A nurse is providing teaching to the parents of a school-age child newly diagnosed with a seizure disorder. The nurse should teach the parents to take which of the following actions during a seizure?
A. Minimize movement of the limbs.
Minimizing movement of the limbs is not a recommended action during a seizure. It is important to allow the seizure to run its course while ensuring the safety of the child.
B. Place the child in a prone position.
Placing the child in a prone position is not recommended during a seizure. The child should be placed in a lateral (side-lying) position to help prevent aspiration and maintain an open airway.
C. Clear the area of hard objects.
This is the correct action. Clearing the area of hard objects helps prevent injury to the child during the seizure. It is important to create a safe environment.
D. Insert a tongue blade between the teeth.
Inserting a tongue blade between the teeth is not recommended. This action can cause injury to the child's mouth or teeth. It is a myth that individuals can swallow their tongue during a seizure.
Full Explanation
A. Minimizing movement of the limbs is not a recommended action during a seizure. It is important to allow the seizure to run its course while ensuring the safety of the child.
B. Placing the child in a prone position is not recommended during a seizure. The child should be placed in a lateral (side-lying) position to help prevent aspiration and maintain an open airway.
C. This is the correct action. Clearing the area of hard objects helps prevent injury to the child during the seizure. It is important to create a safe environment.
D. Inserting a tongue blade between the teeth is not recommended. This action can cause injury to the child's mouth or teeth. It is a myth that individuals can swallow their tongue during a seizure.
A nurse is caring for a 2-month-old infant who has heart failure and is receiving furosemide.
Which of the following findings is the nurse's priority?
A. Negative doll's eye reflex
Negative doll's eye reflex (also known as oculocephalic reflex) is a normal finding in infants. It is a reflexive movement of the eyes in the opposite direction of headmovement.
B. Sunken anterior fontanel
A sunken anterior fontanel can indicate dehydration, which is a concern. However, in a 2-month-old with heart failure, a high heart rate (tachycardia) may indicate worsening of the heart failure and needs to be addressed promptly.
C. Potassium 5.1 mEq/L
A potassium level of 5.1 mEq/L is within the normal range for infants. While electrolyte balance is important, it is not the priority in this situation.
D. Heart rate 162/min
This is the correct answer. A heart rate of 162/min in a 2-month-old infant with heart failure is elevated and requires immediate attention. It may indicate worsening heartfailure or an adverse reaction to the medication (furosemide) being administered. The nurse should assess the infant's condition, notify the healthcare provider, and intervene as necessary.
Full Explanation
A. Negative doll's eye reflex (also known as oculocephalic reflex) is a normal finding in infants. It is a reflexive movement of the eyes in the opposite direction of the head
movement.
B. A sunken anterior fontanel can indicate dehydration, which is a concern. However, in a 2-month-old with heart failure, a high heart rate (tachycardia) may indicate worsening of the heart failure and needs to be addressed promptly.
C. A potassium level of 5.1 mEq/L is within the normal range for infants. While electrolyte balance is important, it is not the priority in this situation.
D. This is the correct answer. A heart rate of 162/min in a 2-month-old infant with heart failure is elevated and requires immediate attention. It may indicate worsening heart
failure or an adverse reaction to the medication (furosemide) being administered. The nurse should assess the infant's condition, notify the healthcare provider, and intervene as necessary.
A nurse is providing teaching to a parent of a child who has HIV. Which of the following statements by the parent indicates an understanding of the teaching?
A. "I will ensure that my child is tested for tuberculosis every year."
This is the correct statement. Children with HIV are at increased risk for tuberculosis (TB) infection. Therefore, regular testing for TB is an important part of their healthcare.
B. "My child will need to double his medications for the next 6 months."
Doubling medications without specific guidance from the healthcare provider can be dangerous and is not recommended. It's important for the parent to follow the prescribed medication regimen as directed.
C. "The risk of transmission decreases once my child is on zidovudine for 2 weeks."
While zidovudine (AZT) is an important medication for HIV treatment, the statement is not accurate. The risk of transmission does not decrease after only 2 weeks of treatment. It takes longer for the viral load to decrease significantly.
D. "My child will need to repeat his childhood immunizations once he is in remission."
Children with HIV do not necessarily need to repeat their childhood immunizations once they are in remission. However, the timing and need for vaccinations may beindividualized based on the child's specific circumstances and immune status. This statement does not demonstrate a clear understanding of the teaching.
Full Explanation
A. This is the correct statement. Children with HIV are at increased risk for tuberculosis (TB) infection. Therefore, regular testing for TB is an important part of their healthcare.
B. Doubling medications without specific guidance from the healthcare provider can be dangerous and is not recommended. It's important for the parent to follow the prescribed medication regimen as directed.
C. While zidovudine (AZT) is an important medication for HIV treatment, the statement is not accurate. The risk of transmission does not decrease after only 2 weeks of
treatment. It takes longer for the viral load to decrease significantly.
D. Children with HIV do not necessarily need to repeat their childhood immunizations once they are in remission. However, the timing and need for vaccinations may be
individualized based on the child's specific circumstances and immune status. This statement does not demonstrate a clear understanding of the teaching.