The nurse is administering a blood transfusion to a 12-year-old child after a motor vehicle crash. About 15 minutes after beginning the transfusion, the child reports trouble breathing. The child's temperature is now 101.2°F (38.4°C) up from a baseline of 98.8°F (37.1°C). Which action would the nurse do next?

Give intravenous diphenhydramine (Benadryl) as ordered

Check the child's apical pulse.

Stop the transfusion

Collect a urine sample.

Answer and Explanation

The Correct Answer is C

A. While administering diphenhydramine may be appropriate for allergic reactions, the priority action is to first stop the transfusion to assess and manage the situation appropriately.

B. Checking the child's apical pulse may provide additional information, but it is not the immediate priority in response to trouble breathing.

C. Stopping the transfusion is the critical first step in managing a suspected transfusion reaction, particularly since the child is exhibiting respiratory distress and a fever, which could indicate an acute hemolytic or allergic reaction.

D. Collecting a urine sample may be indicated later, particularly if a hemolytic reaction is suspected, but it is not an immediate priority over stopping the transfusion and ensuring patient safety.

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Correct Answer is C

Explanation

A. Soccer is a contact sport with a high risk of injury, which is not suitable for a child with hemophilia.

B. Gymnastics can also pose risks of falls and injuries that are not advisable for children with bleeding disorders.

C. Swimming is generally considered safe for children with hemophilia as it is a non-contact activity and does not involve high risk of injury.

D. Football is a contact sport and carries a high risk of trauma, making it unsafe for children with hemophilia.

A. Weighing on the same scale each day B. Testing the urine for glucose levels regularly C. Increasing fluid intake by 50 ml per hour D. Ambulating 3 to 4 times a day E. Complete the course of prescribed antibiotics

Correct Answer is A

Explanation

A. Weighing the child daily on the same scale is critical for monitoring fluid retention and managing edema, which are primary concerns in nephrotic syndrome.

B. Testing urine for glucose levels is not a routine part of nephrotic syndrome management, as glucose levels are not typically affected by this condition.

C. Increasing fluid intake is not advisable in nephrotic syndrome if there is significant edema; fluid management must be tailored to the child's condition.

D. While ambulation is beneficial, it is not as critical as daily weight monitoring in managing nephrotic syndrome.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The parents of a child with hemophilia ask the nurse about appropriate activities and sports that they should encourage the child to participate in. What activity would be the safest for the nurse to suggest?

Correct Answer is C

Explanation

In caring for a child with nephrotic syndrome, which intervention will be most important to be included in the child's plan of care?

Correct Answer is A

Explanation

A child with a brain tumor has a decreased respiratory hate and is less responsive to verbal commands than he was when the nurses assessed the client the previous hour. What should the nurse do next?

A nurse is caring for a child with a urinary tract infection. Which of the following should the nurse include in teaching for the child and family? Select all that apply

A nurse is caring for a 4-month-old infant who is one day postoperative following surgical repair of a cleft lip. Which of the following actions should the nurse take? Select all that apply

A parent calls a clinic and reports to a nurse that his 2-month-old infant is hungry more than usual but is having projectile vomiting immediately after eating Which of the following responses should the nurse make?

A nurse is providing teaching to a 17-year-old female client who has severe acne about the use of isotretinoin. Which of the following adverse effects should the nurse instruct the client is the priority to report immediately to the provider?

A 3 year old child with upper respiratory infection and low-grade fever is being treated with Acetominophen. The nurse is reviewing important anticipatory guidance with the parents which statement by the parents indicates the need for further teaching about this medication?

A 9-year-old client presents to the emergency department after a bee sting and experiencing bouts of nausea and vomiting. The nurse notes the client's blood pressure is 68/40 mm Hg, pulse is 148 beats/minute. 02 saturation is 86%, and the child is dyspneic. Which action is the nurse's priority?