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.
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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Administering Children's Tylenol (acetaminophen) is appropriate for pain relief in toddlers and does not indicate a need for further teaching.
B. Children's Ibuprofen is also acceptable for pain management in this age group, demonstrating the caregiver's understanding of pain management options.
C. Completing the entire course of antibiotics is essential to ensure the infection is fully treated and helps prevent antibiotic resistance.
D. Baby aspirin is contraindicated in children due to the risk of Reye’s syndrome, indicating that the caregiver needs further teaching regarding safe medication administration for pain.
Correct Answer is D
Explanation
A. Removing nits with a fine-tooth comb is a crucial step in managing head lice to prevent re-infestation.
B. Washing bedding and clothing in hot water or sealing non-washable items helps eliminate lice and nits from the environment.
C. Soaking combs and brushes in hot water with shampoo helps ensure that any lice or nits on the grooming tools are eradicated.
D. All of the provided options are appropriate measures for managing pediculosis capitis effectively.
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