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 B
Explanation
A. Acetaminophen can be given every 4 to 6 hours, but every 2 hours is too frequent and indicates a need for further teaching.
B. The maximum daily dose for a child should be based on their weight and typically should not exceed 75 mg/kg/day; stating 4000 mg is too high for a child, indicating a misunderstanding of dosing.
C. Administering acetaminophen rectally is appropriate if the child cannot take it orally, particularly during vomiting episodes.
D. Notifying the provider about jaundice is critical, as it may indicate liver dysfunction, which is important when using acetaminophen.
Correct Answer is ["B","F"]
Explanation
A. Small bladder capacity can contribute to enuresis but may not need to be ruled out before addressing psychological factors.
B. Urinary tract infections can cause enuresis and should be evaluated and treated before investigating psychological causes.
C. Stress incontinence typically refers to the involuntary loss of urine due to pressure and may be a psychological factor rather than a physiological cause.
D. Regression can be a behavioral response but is not a medical cause that needs to be ruled out.
E. Cognitive dysfunction can contribute to enuresis but is not primarily a medical cause that needs to be ruled out.
F. Diabetes mellitus can lead to increased urination (polyuria) and should be evaluated as a potential medical cause before considering psychological factors.
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