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 B

Explanation

A. Keeping a written document of the treatment plan is essential for ensuring continuity of care and effective communication with healthcare providers.

B. Parents should notify their provider immediately, rather than waiting for the next business day, if their child has a sore throat, as this could indicate a possible infection in an immunocompromised child.

C. Using acetaminophen is generally appropriate for managing pain or fever in children receiving chemotherapy, but it should be done with caution regarding dosage and timing.

D. Maintaining a written list of medical appointments helps keep track of the child’s care and is a good practice for managing their health.

A. "She might lose some weight initially” B. “This drug helps to control the abdominal cramping” C. "We should not stop this medication abruptly” D. "We might notice some of the medication in her stool”

Correct Answer is C

Explanation

A. Weight loss may occur with acute exacerbations but is not a guaranteed effect of prednisone therapy.

B. Prednisone does help reduce inflammation but does not directly relieve abdominal cramping; this statement may reflect a misunderstanding of its action.

C. This statement indicates a clear understanding of the need for gradual tapering of prednisone to prevent withdrawal symptoms and rebound exacerbation.

D. Noticing some medication in the stool is not a common or expected effect of prednisone and may indicate a misunderstanding of how the drug works.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reviewing the discharge plan with the family of an 8 year child with acute lymphoblastic leukemia who is receiving chemotherapy through a central venous access device. Which statement by the parent indicates the need for further teaching?

Correct Answer is B

Explanation

A child is experiencing an acute exacerbation of Crohn disease for which she is prescribed prednisone. The nurse teaches the parents and child about this medication. Which statement by the parents indicates that the teaching was successful?

Correct Answer is C

Explanation

A 6 year old child presents to the pediatric clinic with vesicular rash and honey crusted plaques around the nose and mouth. Which of the following statements by the parent indicates the need for further teaching?

A nurse is planning care for a client who has acute glomerulonephritis. Which of the following interventions should the nurse include in the plan?

A nurse is caring for a year old child who has had watery diarrhea for the past 3 days. Which of the following is the most appropriate action for the nurse to take?

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?

The nurse is caring for a 2 month old child with a fever of 101.76. The child also appears toxic with poor color. Which of the following actions would the nurse expect to implement as a priority?

A nurse is teaching a parent of a child who has hemophilia how to control a minor bleeding episode. Which of the following statements by the parent indicates a need for further teaching?

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