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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Blood pressure can fluctuate and may not accurately reflect fluid loss in an infant, especially in early stages of dehydration.
B. Respiratory rate may increase with distress but is not a direct indicator of fluid loss.
C. Skin integrity can show signs of dehydration, but it is not as definitive as changes in body weight.
D. Body weight is the most reliable indicator of fluid loss, as it reflects changes in fluid status directly and provides a clear measure for assessing hydration.
Correct Answer is B
Explanation
A. While abdominal surgery may be needed in some cases of intussusception, non-surgical interventions are often attempted first.
B. An enema with air infusion (often a contrast enema) can be used to treat intussusception by helping to unfold the intestine, making it a commonly discussed procedure.
C. An ano-rectal pull-through procedure is not related to intussusception and is usually indicated for conditions like Hirschsprung's disease.
D. A colostomy may be necessary in cases of bowel necrosis or perforation but is not the first-line treatment for intussusception.
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