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 B

Explanation

A. Switching to a different formula may not address the underlying issue and could lead to further complications.

B. Bringing the baby to the clinic is essential as projectile vomiting in an infant can indicate a serious condition such as pyloric stenosis that requires evaluation and intervention.

C. Giving oral rehydration solutions is not appropriate before assessing the infant's condition, especially if there’s a possibility of a serious underlying issue.

D. While burping is generally recommended, it is not the solution to the problem of projectile vomiting and does not address the need for urgent assessment.

A. Soccer B. Gymnastics C. Swimming D. Football

Correct Answer is C

Explanation

A. Soccer is a contact sport with a high risk of injury, which is not suitable for a child with hemophilia.

B. Gymnastics can also pose risks of falls and injuries that are not advisable for children with bleeding disorders.

C. Swimming is generally considered safe for children with hemophilia as it is a non-contact activity and does not involve high risk of injury.

D. Football is a contact sport and carries a high risk of trauma, making it unsafe for children with hemophilia.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A parent calls a clinic and reports to a nurse that his 2-month-old infant is hungry more than usual but is having projectile vomiting immediately after eating Which of the following responses should the nurse make?

Correct Answer is B

Explanation

The parents of a child with hemophilia ask the nurse about appropriate activities and sports that they should encourage the child to participate in. What activity would be the safest for the nurse to suggest?

Correct Answer is C

Explanation

In caring for a child with nephrotic syndrome, which intervention will be most important to be included in the child's plan of care?

A nurse is discharging a child who has sickle cell anemia after an acute crisis episode. Which of the following instructions should the nurse include in the teaching?

A nurse in an emergency department is caring for an Infant who has a 2-day history of vomiting and an elevated temperature. Which of the following should the nurse recognize as the most reliable indicator of fluid loss?

A nurse is admitting a child who has sepsis and a critically low platelet count. Based on this information which of the following precautions should the nurse initiate?

The nurse is caring for a 2 month old child with a fever of 101.76. The child also appears toxic with poor color. Which of the following actions would the nurse expect to implement as a priority?

A nurse is caring for an adolescent who has hemophilia A and is scheduled for wisdom teeth extractions. Prior to the procedure, the nurse should anticipate that the client will receive which of the following products?