ATI RN
ATI Nur 270 Pediatrics GI GU Exam Questions
Extract:
A 12-year-old child receiving a blood transfusion after a motor vehicle crash, reports trouble breathing 15 minutes after starting, temperature 101.2°F up from 98.8°F
Question 1 of 5
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?
Correct Answer: C
Rationale: The correct action for the nurse to take next is to stop the transfusion (
Choice
C). The child's symptoms of trouble breathing and increased temperature suggest a possible transfusion reaction, such as a febrile non-hemolytic reaction or an acute hemolytic reaction. Stopping the transfusion is crucial to prevent further complications and ensure the child's safety. Additionally, the nurse should assess the child's vital signs, respiratory status, and overall condition, and notify the healthcare provider immediately for further instructions and management. Giving diphenhydramine (
Choice
A) may be indicated for allergic reactions, but in this scenario, stopping the transfusion takes precedence. Checking the child's apical pulse (
Choice
B) may provide information on the child's heart rate but does not address the immediate concern of potential transfusion reaction. Collecting a urine sample (
Choice
D) is not relevant or urgent in this situation.
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