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. Constipation can occur but is not a direct symptom of sickle cell crisis; it’s more related to hydration and diet.
B. High fever may occur due to infection, but it is not a guaranteed finding in every sickle cell crisis.
C. Bradycardia is not typically associated with sickle cell crisis; tachycardia is more common due to pain and stress.
D. Pain is the hallmark symptom of a sickle cell crisis due to vaso-occlusive episodes leading to ischemia and tissue damage.
Correct Answer is D
Explanation
A. While monitoring temperature can be important, it is not the primary focus post-crisis unless there are specific concerns.
B. Cold compresses can constrict blood vessels and worsen sickling; heat is usually recommended for pain relief in sickle cell crisis.
C. Restricting outdoor play is not necessary; children with sickle cell anemia should be encouraged to engage in regular activities within their limits.
D. Offering fluids frequently helps prevent dehydration, which can trigger a sickle cell crisis, making it an essential part of discharge teaching.
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