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. Antibiotics are not routinely indicated for acute glomerulonephritis unless there is an underlying infection; the condition is often related to an immune response.
B. Monitoring weight is crucial in acute glomerulonephritis to assess for fluid retention and manage edema effectively.
C. Fluid intake may need to be restricted to manage hypertension and edema, so encouraging increased intake is not appropriate.
D. While ambulation is important for general health, it is not a primary intervention for managing acute glomerulonephritis.
Correct Answer is C
Explanation
A. Respiratory precautions are necessary for preventing the spread of respiratory infections but are not specifically indicated here.
B. Airborne precautions are required for diseases transmitted through the air (e.g., TB), not relevant in this scenario.
C. Bleeding precautions should be initiated due to the critically low platelet count, as this increases the risk of bleeding complications. Nurses should be vigilant in monitoring for signs of bleeding and minimizing invasive procedures.
D. Contact precautions are important for preventing the spread of infections, but in this case, the primary concern is bleeding due to low platelet counts.
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