A nurse is caring for a 7-year-old male client who sustained a traumatic injury to the left leg after being struck by a lawnmower while playing outside.

Exhibits

Complete the diagram by dragging from the choices area to specify which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress.

Choice A rationale

Noting the date and time of the behavior is the first step in addressing the issue, providing a record for future reference and ensuring accuracy in documentation.

Choice C rationale

Planning for scheduled break times helps address potential reasons for the behavior, offering a structured solution to prevent recurrence and improve overall workflow.

Choice B rationale

Evaluating the UAP for signs of improvement is the final step, assessing whether the implemented interventions have been effective and if further actions are needed.

Choice A rationale

Stopping the blood transfusion is critical to prevent the progression of a transfusion reaction, which can be life-threatening. Immediate cessation of the transfusion minimizes the amount of incompatible blood entering the patient’s system, reducing the risk of serious complications such as hemolysis or anaphylaxis. Rapid intervention is necessary to ensure the patient’s safety and to provide time for assessment and implementation of appropriate treatments. Recognizing the signs of a transfusion reaction and acting swiftly is essential in managing the patient’s condition effectively.

Choice B rationale

Administering an antipyretic is not the priority action when a transfusion reaction is suspected. Fever can be a symptom of a transfusion reaction, but stopping the transfusion and assessing the patient are more urgent. Antipyretics like acetaminophen can be given to manage fever, but only after the transfusion is halted and the patient’s overall condition has been evaluated. Addressing the root cause of the reaction takes precedence to prevent further complications.

Choice C rationale

Encouraging oral fluids is not an immediate priority during a transfusion reaction. While maintaining hydration is important, the initial step must be to stop the transfusion and assess the patient’s condition. Oral fluids do not address the underlying issue of the transfusion reaction and are not effective in managing acute symptoms. Prioritizing actions that directly mitigate the reaction is essential for patient safety.

Choice D rationale

Applying supplemental oxygen may be necessary if the patient exhibits signs of respiratory distress during a transfusion reaction. However, the first action should be to stop the transfusion to prevent further exposure to the incompatible blood product. Oxygen can be administered as a supportive measure after the transfusion is halted and the patient’s respiratory status is assessed. Addressing the immediate cause of the reaction is paramount.

Choice E rationale

Sending blood for type and crossmatch is important for identifying the cause of the transfusion reaction and ensuring safe future transfusions. However, this action is not the priority during the acute phase of a reaction. Stopping the transfusion and assessing the patient’s condition must come first to stabilize the patient and prevent further complications. Laboratory testing can be performed once the patient’s immediate needs are addressed.