a nurse is caring for a child with a diagnosis of acute lymphoblastic leukemia all what is the priority nursing intervention
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Nursing Elites

HESI LPN

Pediatric HESI 2024

1. A nurse is caring for a child with a diagnosis of acute lymphoblastic leukemia (ALL). What is the priority nursing intervention?

Correct answer: A

Rationale: The correct answer is A: Administering chemotherapy. In the care of a child with acute lymphoblastic leukemia (ALL), the priority nursing intervention is administering chemotherapy. Chemotherapy is the primary treatment for ALL and plays a crucial role in managing the disease. While preventing infection, monitoring for signs of bleeding, and providing nutritional support are important aspects of caring for a child with ALL, administering chemotherapy takes precedence as it directly targets the cancer cells and aims to induce remission.

2. Which of the following statements regarding 2-rescuer child CPR is correct?

Correct answer: B

Rationale: The correct statement regarding 2-rescuer child CPR is to compress the chest with one or two hands to a depth equal to one-half to one third the diameter of the chest. This technique ensures effective chest compressions without causing excessive damage to the chest. Choice A is incorrect because allowing the chest to fully recoil between compressions is essential to facilitate optimal blood flow during CPR. Choice C is incorrect as it describes a compression to ventilation ratio of 30:2, which is not the recommended ratio for child CPR. Choice D is incorrect as a compression to ventilation ratio of 15:2 is not standard practice for child CPR, and pauses in compressions are necessary to provide ventilations effectively.

3. A child with a diagnosis of pyloric stenosis is scheduled for surgery. What preoperative intervention is important for the nurse to perform?

Correct answer: C

Rationale: The correct preoperative intervention for a child with pyloric stenosis is to monitor for signs of dehydration. Pyloric stenosis involves the obstruction of the pyloric sphincter, leading to projectile vomiting, which can result in dehydration and electrolyte imbalances. Monitoring for signs of dehydration is crucial to assess the child's fluid status and prevent complications. Administering intravenous fluids, although important in managing dehydration, is not typically a preoperative intervention but rather a treatment during or after surgery. Monitoring for signs of infection and pain may also be important but are not the priority preoperative interventions in a child with pyloric stenosis.

4. When preparing a 2-year-old child for surgery, what preoperative teaching should be provided to help them understand the procedure?

Correct answer: B

Rationale: The correct preoperative teaching for a 2-year-old child undergoing surgery involves using a doll to demonstrate the procedure. This method helps the child understand what to expect in a non-threatening and visual way, making the experience less intimidating. Explaining the procedure in simple terms (Choice A) may not effectively convey the details to a young child. Showing pictures of the hospital environment (Choice C) may not directly address the surgical procedure itself. Allowing the child to play with medical equipment (Choice D) can be unsafe and may not effectively prepare the child for the surgery.

5. An 8-year-old girl was diagnosed with a closed fracture of the radius at approximately 2 p.m. The fracture was reduced in the emergency department, and her arm placed in a cast. At 11 p.m., her mother brings her back to the emergency department due to unrelenting pain that has not been relieved by the prescribed narcotics. Which action would be the priority?

Correct answer: A

Rationale: The correct action would be to notify the doctor immediately. Unrelenting pain despite medication can indicate compartment syndrome, which is a medical emergency requiring immediate attention. Applying ice or elevating the arm may not address the potential serious underlying issue of compartment syndrome. Giving additional pain medication without further assessment could delay necessary intervention and potentially worsen the condition.

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