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.

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Correct Answer is C

Explanation

A. Weight loss may occur with acute exacerbations but is not a guaranteed effect of prednisone therapy.

B. Prednisone does help reduce inflammation but does not directly relieve abdominal cramping; this statement may reflect a misunderstanding of its action.

C. This statement indicates a clear understanding of the need for gradual tapering of prednisone to prevent withdrawal symptoms and rebound exacerbation.

D. Noticing some medication in the stool is not a common or expected effect of prednisone and may indicate a misunderstanding of how the drug works.

A. Raise the head of the bed B. Notify the health care provider (HCP) C. Obtain an oximeter reading D. Implement seizure precautions

Correct Answer is B

Explanation

A. Raising the head of the bed may help with respiratory effort but does not address the underlying issue of decreased responsiveness. Immediate assessment and intervention are necessary.

B. Notifying the healthcare provider is critical as the child’s decreased responsiveness and respiratory rate indicate a potential deterioration in condition that requires prompt medical evaluation.

C. While obtaining an oximeter reading can provide useful information about oxygenation, the priority is to notify the HCP about the change in the child's neurological status.

D. Implementing seizure precautions is important for a child with a brain tumor, but the immediate concern is the change in responsiveness, necessitating HCP notification first.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A child is experiencing an acute exacerbation of Crohn disease for which she is prescribed prednisone. The nurse teaches the parents and child about this medication. Which statement by the parents indicates that the teaching was successful?

Correct Answer is C

Explanation

A child with a brain tumor has a decreased respiratory hate and is less responsive to verbal commands than he was when the nurses assessed the client the previous hour. What should the nurse do next?

Correct Answer is B

Explanation

The nurse is providing care to a child with acute abdominal pain, currant-jelly-like stools and suspected intussusception. The nurse will discuss with the caregivers that the child will have which procedure

A nurse in a pediatric clinic is caring for a child who has iron deficiency anemia and a new prescription for ferrous sulfate tablets. Which of the following instructions should the nurse provide the parents regarding administration of this medication?

The nurse is reviewing appropriate nutritional options for a child who is receiving chemotherapy and has been prescribed a neutropenic diet. The nurse would recommend which of the following options

A nurse is planning a diet for a client who is iron deficient. Which of the following foods high in iron should the nurse include in the plan?

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 has completed an education session with parents of children diagnosed with peanut allergy. Which statement by a parent would indicate a need for additional education?

A nurse is caring for a 4-month-old infant who is one day postoperative following surgical repair of a cleft lip. Which of the following actions should the nurse take? Select all that apply

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.