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 ["300"]
Explanation
To calculate the dose of ceftriaxone for the child, first convert the child's weight from pounds to kilograms, knowing that 1 kilogram equals 2.2 pounds. The child weighs 33 pounds, which is approximately 15 kilograms when divided by 2.2. The prescribed dose is 60 mg/kg/day, so for a 15 kg child, this would be 900 mg per day. Since the medication is to be administered in three divided doses, you would divide 900 mg by 3, resulting in 300 mg per dose.
Correct Answer is ["A","D","E"]
Explanation
A. Positioning the infant on their back and upright in Semi-Fowler's helps prevent aspiration and supports respiratory function after surgery.
B. Encouraging parents to hold the baby is important for bonding, but caution should be taken to avoid placing pressure on the surgical site.
C. Aspirin should not be administered due to the risk of Reye's syndrome; acetaminophen is typically used for pain management in infants.
D. Applying elbow restraints as ordered is necessary to prevent the infant from pulling at the surgical site and to ensure proper healing.
E. Maintaining IV therapy is crucial for nutrition until the infant can take oral feeds safely.
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