While receiving a transfusion of packed red blood cells, a school-aged child begins to experience itchy skin, hiver a tonsillectomy. What should the nurse do first for this child?
Obtain a blood culture.
Stop the transfusion.
Slow the transfusion rate.
Provide a diuretic as prescribed.
The Correct Answer is B
A. Obtaining a blood culture is important but is not the immediate priority when a transfusion reaction is occurring.
B. Stopping the transfusion is the first step in managing a transfusion reaction to prevent further exposure to the allergen or irritant causing the symptoms.
C. Slowing the transfusion rate might not be sufficient if a reaction is occurring; stopping it is crucial.
D. Providing a diuretic is not relevant to the management of an acute transfusion reaction.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. This site is used most often to obtain a pulse in infants during CPR or blood pressure measurement, but it does not provide the most accurate heart rate assessment.
B. The radial artery is not typically used in infants because it is less accessible and not as easily palpated in this age group.
C. The apical pulse (measured with a stethoscope at the 4th intercostal space, left midclavicular line) is the most accurate site for infants and children under 2 years old. It directly reflects the heart’s activity and is less affected by peripheral perfusion.
D. The carotid artery is not typically used for assessing the heart rate in infants due to the risk of applying excessive pressure.
Correct Answer is B
Explanation
Assessing the erythematous rash is important, as it can indicate the presence of erythema marginatum, a common symptom of rheumatic fever, but it is not the priority.
B. Auscultating the rate and characteristics of the child's heart sounds is the priority assessment because acute rheumatic fever can cause carditis, which affects the heart valves and can lead to serious complications. Early detection of any cardiac involvement is crucial for timely intervention and management.
C. Assessing joint pain is necessary for comfort and symptom management but does not take precedence over potential cardiac complications.
D. Identifying parental anxiety is important for providing emotional support but is not the immediate priority in managing the child's acute condition.
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