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 C
Explanation
A. Ibuprofen can be used for fever, but it is important to check if the child has varicella before administering due to potential Reye's syndrome.
B. The child should stay home until all lesions have crusted over to prevent spreading the virus, even if the fever is gone.
C. Once lesions have crusted, the child is no longer contagious, indicating understanding of the contagious period.
D. Using cool or tepid water is acceptable for soothing itching; however, it does not specifically address the need for proper care during the contagious phase.
Correct Answer is B
Explanation
A. Bagels with cream cheese and lox are not recommended as lox may carry a risk of contamination.
B. A vanilla milkshake made with pasteurized milk is safe for a neutropenic diet as pasteurization kills harmful bacteria.
C. Ham and cheese sandwiches may not be safe unless the ham is fully cooked, as deli meats can harbor bacteria.
D. Sushi is not appropriate for a neutropenic diet due to the risk of raw fish and potential bacteria.
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