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.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Free Nursing Study Resources

Correct Answer is ["A","B","D","E","F","H"]

Explanation

A. The WBC count is elevated at 15,000/mm³, which indicates leukocytosis. In a child with leukemia, this could suggest a potential relapse or an ongoing infection, which requires prompt evaluation by the provider.

B. The hemoglobin level is at the lower limit of normal (10 g/dL). This can indicate anemia, which is significant in a child with a history of leukemia and may require further investigation or intervention.

C. While the ongoing upper respiratory infection is concerning, it is less urgent than the other findings. The nurse should monitor this but may not need to report it as a critical finding compared to the child's acute symptoms.

D. The presence of clear breath sounds is expected; however, they should be reported in the context of the child's respiratory distress and the associated findings.

E. An oxygen saturation of 92% on room air is below the normal range and indicates hypoxia. This is a critical finding that requires immediate attention from the provider.

F. Subcostal retractions indicate increased work of breathing and respiratory distress, which is an urgent assessment finding that must be communicated to the provider.

G. While the respiratory rate is relevant, the specific number was not provided, and unless it indicates significant distress or abnormality, it may not be a priority report compared to the other findings.

H. The presence of petechiae is concerning, especially in a child with a history of leukemia. This could indicate thrombocytopenia or another hematological issue, which requires further evaluation by the provider.

A. I can give this medication every 2 hrs for fever B. I can give up to 4000 mg each day by mouth if my child is irritable C. I can give this medication rectally if my child has a fever and is having vomiting D. I will notify the provider notice that the whites of my child's eyes are yellow

Correct Answer is B

Explanation

A. Acetaminophen can be given every 4 to 6 hours, but every 2 hours is too frequent and indicates a need for further teaching.

B. The maximum daily dose for a child should be based on their weight and typically should not exceed 75 mg/kg/day; stating 4000 mg is too high for a child, indicating a misunderstanding of dosing.

C. Administering acetaminophen rectally is appropriate if the child cannot take it orally, particularly during vomiting episodes.

D. Notifying the provider about jaundice is critical, as it may indicate liver dysfunction, which is important when using acetaminophen.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Exhibits Which of the following assessment findings should the nurse report to the provider? Select the 6 findings that should be reported to the provider.

Correct Answer is ["A","B","D","E","F","H"]

Explanation

A 3 year old child with upper respiratory infection and low-grade fever is being treated with Acetominophen. The nurse is reviewing important anticipatory guidance with the parents which statement by the parents indicates the need for further teaching about this medication?

Correct Answer is B

Explanation

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?

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 is planning care for an adolescent client. Exhibits Which of the following actions should the nurse plan to 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.

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 client who is HIV positive and is one day postoperative following an appendectomy. The nurse should wear a gown as personal protective equipment when taking which of the following actions?

A nurse is preparing to discharge a child who has a new prescription for an oral antibiotic. Which of following information should the nurse include in the discharge instructions? (Select all that apply.)