A 12-year-old child is undergoing a blood transfusion via an infusion pump and begins to complain of “itchy skin” 15
minutes after the start of the blood unit.
The child appears flushed.
What action should the practical nurse (PN) take?
Stop the transfusion.
Prepared by Dr Paul Mugo
11 Page of 77
Inspect the infusion site.
Apply lotion to the skin.
The Correct Answer is A
Choice A rationale
If a child undergoing a blood transfusion complains of itchy skin and appears flushed, these
could be signs of a transfusion reaction. The PN should stop the transfusion immediately.
Choice B rationale
While inspecting the infusion site is a part of regular monitoring during a transfusion, it would
not typically be the first action in response to symptoms of a possible transfusion reaction.
Choice C rationale
Applying lotion to the skin would not address the underlying issue if the child is experiencing a
transfusion reaction.
Choice D rationale
Checking the vital signs is important, but the first action should be to stop the transfusion if a
reaction is suspected.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Metronidazole is an antibiotic used to treat various infections. Seizure activity is a serious side effect of metronidazole and should be reported to the charge nurse immediately.
Choice B rationale
While headache is a common side effect of metronidazole, it is not as serious as seizure activity and does not necessarily need to be reported to the charge nurse unless it is severe or persistent.
Choice C rationale
A metallic taste in the mouth is a common side effect of metronidazole. It is not a serious side effect and does not need to be reported to the charge nurse.
Choice D rationale
Abdominal cramping can be a side effect of metronidazole. However, it is not as serious as seizure activity and does not necessarily need to be reported to the charge nurse unless it is severe or persistent.
Correct Answer is D
Explanation
The correct answer is Choice D. Rationale:
Rivaroxaban is an anticoagulant medication used to treat and prevent blood clots. One of the common side effects of rivaroxaban is bruising. This occurs because rivaroxaban prevents blood clots by thinning the blood, which can lead to increased bleeding and bruising. If a patient on rivaroxaban presents with the appearance of bruising in arms and legs, it could indicate excessive bleeding, which is a serious side effect that should be reported immediately.
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