Nokea
What should the nurse closely assess in a child receiving a transfusion?
- A. Fever
- B. Lethargy
- C. Jaundice
- D. Bradycardia
Correct Answer: A
Rationale: The child receiving a blood transfusion is observed for signs of a transfusion reaction including chills, itching, fever, rash, headache, and back pain.
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What is the result of a deficiency of factor IX?
- A. Thalassemia
- B. Idiopathic thrombocytopenic purpura
- C. Hemophilia A
- D. Christmas disease
Correct Answer: D
Rationale: Christmas disease, or hemophilia B, is caused by the deficiency of factor IX.
The nurse is dealing with a preschool child with a life-threatening illness. What should the nurse remember the child's concept of death is at this age?
- A. That it is final
- B. Only a fear of separation from her parents
- C. That a person becomes alive again soon after death
- D. An understanding based on simple logic
Correct Answer: C
Rationale: The preschooler views death as reversible and temporary.
An adolescent is diagnosed with Hodgkin's disease. Lymph nodes on both sides of her diaphragm have been found to be involved, including cervical and inguinal nodes. Which disease stage is this?
- A. I
- B. II
- C. III
- D. IV
Correct Answer: C
Rationale: Lymph node regions on both sides of the diaphragm are consistent with a diagnosis of stage-III Hodgkin's disease.
A 3-year-old child with sickle cell disease is admitted to the hospital in sickle cell crisis with severe abdominal pain. Which type of crisis is the child most likely experiencing?
- A. Aplastic
- B. Hyperhemolytic
- C. Vaso-occlusive
- D. Splenic sequestration
Correct Answer: C
Rationale: Vaso-occlusive crisis, or painful crisis, is caused by obstruction of blood flow by sickle cells, infarctions, and some degrees of vasospasm.
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.