A 12-year-old child is undergoing a blood transfusion via an infusion pump and begins to complain of “itchy skin” 15
minutes after the start of the blood unit.
The child appears flushed.
What action should the practical nurse (PN) take?
Stop the transfusion.
Prepared by Dr Paul Mugo
11 Page of 77
Inspect the infusion site.
Apply lotion to the skin.
The Correct Answer is A
Choice A rationale
If a child undergoing a blood transfusion complains of itchy skin and appears flushed, these
could be signs of a transfusion reaction. The PN should stop the transfusion immediately.
Choice B rationale
While inspecting the infusion site is a part of regular monitoring during a transfusion, it would
not typically be the first action in response to symptoms of a possible transfusion reaction.
Choice C rationale
Applying lotion to the skin would not address the underlying issue if the child is experiencing a
transfusion reaction.
Choice D rationale
Checking the vital signs is important, but the first action should be to stop the transfusion if a
reaction is suspected.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["F"]
Explanation
Choice A rationale
A pain rating of 2/10 is not directly related to the therapeutic effect of Bisacodyl. Bisacodyl is a stimulant laxative used to treat constipation, and its effectiveness would not typically be measured by pain ratings20.
Choice B rationale
A non-blanchable red area could be a sign of a pressure ulcer or other skin condition. It is not a therapeutic result of Bisacodyl administration20.
Choice C rationale
Blood pressure of 135/81 mmHg is a normal reading and is not directly related to the therapeutic effect of Bisacodyl20.
Choice D rationale
Sinus tachycardia, or a faster-than-normal heart rate, is not a therapeutic result of Bisacodyl administration. If a patient experiences sinus tachycardia while taking Bisacodyl, they should seek medical attention20.
Choice E rationale
Itching in legs is not a therapeutic result of Bisacodyl administration. It could be a sign of an allergic reaction or other medical condition20.
Choice F rationale
Semifluid stool is the correct answer. Bisacodyl is a stimulant laxative that works by increasing activity in the intestines to cause a bowel movement. Therefore, the production of semifluid stool can be considered a therapeutic result of Bisacodyl administration20.
Choice G rationale
A burning sensation is not a therapeutic result of Bisacodyl administration. If a patient experiences a burning sensation while taking Bisacodyl, they should seek medical attention20.
Correct Answer is D
Explanation
The correct answer is Choice D, Hold the medication until the meal tray arrives. Acarbose is an oral antidiabetic medication that works by slowing the digestion of carbohydrates in the small intestine, thereby reducing the rise in blood glucose after meals. It is important to take acarbose at the start of each main meal, as it works on the food that is consumed. If the meal is delayed, the medication should also be delayed.
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