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The child receiving a transfusion complains of back pain and itching. What is the best initial action by the nurse?
- A. Notify the charge nurse.
- B. Disconnect intravenous lines immediately.
- C. Give diphenhydramine (Benadryl).
- D. Clamp off blood and keep line open with normal saline.
Correct Answer: D
Rationale: If a blood transfusion reaction occurs, the first action is to stop the blood infusion, keep the line open with normal saline, and notify the charge nurse.
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Why would the nurse urge the family of a dying 12-year-old boy to include his 8-year-old sister in care? (Select all that apply.)
- A. She will feel less neglected by the parents.
- B. She can make amends for past hostilities to her brother.
- C. She will feel increased helplessness.
- D. She can express her feelings through care.
- E. She can experience being supportive of her parents and brother.
Correct Answer: A,B,D,E
Rationale: Including the sibling in care helps reduce feelings of neglect, allows expression of feelings, and fosters a sense of support and connection.
A child has just been diagnosed with acute lymphoblastic leukemia. What is the result of an overproduction of immature white blood cells in the bone marrow?
- A. Decreased T-cell production
- B. Decreased hemoglobin
- C. Increased blood clotting
- D. Increased susceptibility to infection
Correct Answer: D
Rationale: An overproduction of immature white blood cells increases the child's susceptibility to infection.
A 2-year-old child has been diagnosed with hemophilia A. What information should the nurse include in a teaching plan about home care?
- A. If bleeding occurs, apply pressure, ice, elevate, and rest the extremity.
- B. Children's aspirin in lowered doses may be given for joint discomfort.
- C. A firm, dry toothbrush should be used to clean teeth at least twice a day.
- D. Do not permit interactive play with other children.
Correct Answer: A
Rationale: When bleeding occurs, the traditional approach is to follow RICE - rest, ice, compression, and elevation.
The most recent blood count for a child who received chemotherapy last week shows neutropenia. What is the priority nursing diagnosis for this child?
- A. Risk for infection
- B. Risk for hemorrhage
- C. Altered skin integrity
- D. Disturbance in body image
Correct Answer: A
Rationale: The child with neutropenia is at risk for infection.
What will the nurse administer with ferrous sulfate drops when providing them to a child on the pediatric unit?
- A. With milk
- B. With orange juice
- C. With water
- D. On a full stomach
Correct Answer: B
Rationale: Vitamin C aids in the absorption of iron, whereas food and milk interfere with the absorption of iron.