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.

Nursing Test Bank

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Correct Answer is D

Explanation

A. Encouraging handwashing is important to prevent spreading infection and shows understanding of hygiene practices.

B. Advising the child not to touch their face is important to prevent secondary infections and spread of the rash.

C. Providing a separate towel helps prevent the spread of infection, demonstrating good understanding of precautions.

D. Filling a prescription for antiviral ointment is inappropriate in this case; the honey-crusted plaques suggest impetigo, which is typically treated with topical or oral antibiotics, not antiviral ointment.

A. I will keep a written document of the treatment plan B. I will notify my provider on the next business day if my child has a sore throat C. I will use acetominophen if my child needs an analgesic for pain D. I will keep a written list of all my child's medical appointments

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.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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?

Correct Answer is D

Explanation

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

The nurses reviewing triggers of sickle cell crisis with a 14-year-old male client with sickle cell anemia. Which statement by the client indicates an understanding of the teaching? Select all that apply.

The nurse is reviewing management of pediculosis capitis with the parents of school age children during a presentation in addition to medicated shampoo or cream rinse, the treatment for head lice may also include which of the following?

A nurse is caring for a toddler who has acute otitis media. Which of the following is the priority action for the nurse to take?

A nurse is admitting a child who has sepsis and a critically low platelet count. Based on this information which of the following precautions should the nurse initiate?

The nurse is discussing the treatment of congenital aganglionic megacolon (Hirschsprungs disease) with the caregivers of a 3-day-old newborn infant who presented with abdominal distension and failure to pass meconium. Which statement is the best explanation of the treatment for this diagnosis?