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 B
Explanation
A. While prophylactic antibiotics may be considered, they are not standard for all procedures in hemophilia management.
B. Recombinant factor VIII is essential to ensure adequate clotting during and after the extraction, minimizing the risk of bleeding complications.
C. Packed RBCs may be needed for severe anemia but are not a standard preventive measure for hemophilia management during dental procedures.
D. Fresh frozen plasma can provide clotting factors but is not the preferred treatment for hemophilia A, where specific factor VIII replacement is needed.
Correct Answer is D
Explanation
A. Administering an IV bolus medication does not typically require gowning unless there is a risk of exposure to bodily fluids.
B. Talking to the client does not necessitate wearing a gown, as it does not pose a risk of exposure.
C. Administering an IM injection may require gloves but not necessarily a gown unless there is a risk of splashing.
D. Completing a dressing change involves potential exposure to bodily fluids, so wearing a gown is appropriate for infection control.
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