When the patient experiences apprehension and urticaria while receiving a blood transfusion, the nurse:
slows the transfusion and takes the patient's vital signs.
observes the child for further transfusion reactions.
stops the transfusion, allows normal saline solution to run slowly, and notifies the charge nurse.
stops what he or she is doing and obtains the patient's history.
The Correct Answer is C
A. Slows the transfusion and takes the patient's vital signs: Slowing the transfusion still allows exposure to the allergen. Transfusion should be stopped immediately.
B. Observes the child for further transfusion reactions: Waiting is unsafe; action is required immediately.
C. stops the transfusion, allows normal saline solution to run slowly, and notifies the charge nurse. These are classic signs of an allergic transfusion reaction. The nurse must stop the transfusion immediately, keep the IV line open with normal saline, and notify the charge nurse or provider.
D. Stops what he or she is doing and obtains the patient's history: Immediate intervention is critical; history can be reviewed after stabilizing the patient.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C"]
Explanation
A. Contact precautions: RSV is spread through direct contact with secretions, making contact precautions essential.
B. Standard precautions: Always used for all patients to reduce risk of transmission of pathogens.
C. Droplet precautions: RSV can also be transmitted via large respiratory droplets, so droplet precautions are appropriate.
D. Airborne infection isolation precautions: RSV is not airborne; negative-pressure rooms and N95 masks are not required.
Correct Answer is B
Explanation
A. An 18-month-old crying after cleft palate repair: Crying increases tension on sutures but is not immediately life-threatening.
B. An 8-year-old who is swallowing frequently after tonsillectomy: Frequent swallowing is an early sign of bleeding, a potentially life-threatening complication after tonsillectomy. Requires immediate attention.
C. A 15-year-old with IV pain at the insertion site: This may indicate infiltration or phlebitis but is not an immediate emergency.
D. A 12-year-old refusing to ambulate post-appendectomy: Ambulation is important to prevent complications, but refusal does not signal an urgent clinical issue.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.