A child is to receive a blood transfusion, if an allergic reaction to the blood occurs, the nurse's first intervention should be:
- A. Relieved the symptoms with an ordered
- B. Slow the flow rate antihistamines
- C. Stop the blood immediately
Correct Answer: C
Rationale: In the scenario of a child experiencing an allergic reaction during a blood transfusion, the nurse's first intervention should always be to stop the blood immediately. This is crucial to prevent further complications and adverse reactions in the child. Pausing the transfusion allows for assessment of the allergic reaction's severity, immediate treatment initiation, and alerting the healthcare team for further management. Relieving symptoms with antihistamines or slowing the flow rate would not address the primary concern of stopping the allergen from entering the child's system. Therefore, stopping the blood immediately is the most appropriate and urgent action to take in this situation.
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The MOST appropriate answer to why infants cry in response to another infant's cry is
- A. an early sign of empathy development
- B. a sign of good hearing reflex
- C. a startle reflex
- D. an early sign of fear development
Correct Answer: A
Rationale: Empathy begins developing early, though rudimentary.
Halfway through the administration of a unit of blood, a client complains of lumbar pain. The nurse should:
- A. Obtain vita! Signs
- B. Assess the pain further
- C. Stop the transfusion
- D. Increase the flow of normal saline SITUATION: James, A 27 basketball player sustained inhalation burn that required him to have tracheostomy due to massive upper airway edema.
Correct Answer: C
Rationale: Lumbar pain during a blood transfusion can be a sign of an adverse reaction, such as a transfusion reaction. Any complaints of pain during a transfusion should not be ignored. In this case, the nurse should first stop the transfusion to prevent any further complications. The client should be assessed promptly for other signs of a transfusion reaction, and appropriate actions should be taken as needed to ensure the client's safety and well-being.
Mr Santos is placed on seizure precaution. Which of the following would be contraindicated?
- A. Obtain his oral temperature g. Allow him to wear his own clothing f. Encourage to perform his own personal h. Encourage him to be out of bed hygiene
Correct Answer: A
Rationale: When a patient is placed on seizure precautions, obtaining oral temperature would be contraindicated. This is because sticking a thermometer in the mouth may pose a risk during a seizure episode, as the patient might bite down on it and cause injury. It is important to prioritize safety measures to minimize the risk of harm to the patient. Other methods of monitoring temperature, such as using a tympanic thermometer or a forehead thermometer, would be more appropriate in this situation.
The nurse is examining 12-month-old Amy, who was brought to the clinic for persistent diaper rash. The nurse finds perianal inflammation with satellite lesions that cross the inguinal folds. What is most likely the cause of the diaper rash?
- A. Impetigo
- B. Candida albicans
- C. Urine and feces
- D. Infrequent diapering
Correct Answer: B
Rationale: The presentation of perianal inflammation with satellite lesions that cross the inguinal folds is highly suggestive of a Candida albicans (yeast) diaper rash. Yeast diaper rash is characterized by redness, swollenness, and usually involves the skin folds. The warm, moist environment created by a diaper provides an ideal setting for Candida albicans to grow and cause a rash. The presence of satellite lesions that cross the inguinal folds further supports the diagnosis of a yeast infection rather than other causes like impetigo, irritation from urine and feces, or infrequent diapering. Treatment for yeast diaper rash typically involves antifungal creams or ointments.
A nurse is teaching a parent of an infant about treatment of seborrhea dermatitis (cradle cap). Which should the nurse include in the instructions?
- A. Shampoo every three days with a mild soap.
- B. The hair should be shampooed with a medicated shampoo.
- C. Shampoo every day with an antiseborrheic shampoo.
- D. The loosened crusts should not be removed with a fine-toothed comb.
Correct Answer: A
Rationale: The nurse should include in the instructions to shampoo every three days with a mild soap. Seborrheic dermatitis, commonly known as cradle cap in infants, is a common condition characterized by greasy, yellowish, scaly patches on the scalp. Mild cases of cradle cap typically do not require aggressive treatment. Using a mild soap and shampooing every few days can help loosen the scales and prevent buildup without causing irritation to the infant's delicate skin. It is important not to shampoo too frequently or use harsh products as this can exacerbate the condition. Additionally, the loosened crusts can be gently massaged and removed after shampooing with a soft brush or cloth, but it is not necessary to use a fine-toothed comb, as this may cause skin irritation.