VERSION 1 A nurse is caring for a school-age child who is receiving a blood transfusion. Which of the following manifestations should alert the nurse to a possible hemolytic transfusion reaction? a. Laryngeal edema b. Flank pain c. Distended neck veins d. Muscular weakness Answer- b. Flank pain. The nurse should recognize that flank pain is caused by the breakdown of RBCs and is an indication of a hemolytic reaction to the blood transfusion. A- Laryngeal edema is an indication of an allergic reaction to the blood transfusion. C- Distended neck veins are an indication of circulatory overload, which is a complication of a blood transfusion. D- Muscle weakness is an indication of an electrolyte disturbance, which is a complication of a blood transfusion. A community health nurse is assessing an 18-month-old toddler in a community day care. Which of the following findings should the nurse identify as a potential indication of physical neglect? a. Resists having an axillary temperature taken b. Exhibits withdrawal behaviors when her parent leaves c. Has multiple bruises on her knees d. Poor personal hygiene Answer- d. Poor personal hygiene. Poor personal hygiene in a toddler is a potential indication of physical neglect. Because toddlers are still dependent on their parents for help with hygiene needs, poor personal hygiene indicates a lack of supervision. A- The toddler has begun to develop a sense of body image and boundaries and can be resistant to intrusive assessments such as assessing the mouth or ears, or taking an axillary temperature. Therefore, this finding is not an indication of physical neglect. B- Separation anxiety is an expected finding for a toddler. The child of this age can become fearful and exhibit regressive behaviors when left alone with strangers and separated from her parents; therefore, this finding is not an indication of physical neglect. C- The 18-month-old toddler has accomplished the gross motor skills of standing and walking and has begun to try to run but falls easily and can have bruises on her knees. Therefore, this finding is not an indication of physical neglect. A nurse is caring for a school-age child who is receiving chemotherapy and is severely immunocompromised. Which of the following actions should the nurse take? a. Use surgical asepsis when providing routine care for the child. b. Administer the measles, mumps, rubella (MMR) vaccine to the child. c. Screen the child's visitors for indications of infection. d. Infuse packed RBCs. Answer- c. Screen the child's visitors for indications of infection. The child who is severely immunocompromised is unable to adequately respond to infectious organisms resulting in the potential for overwhelming infection; therefore, the nurse should screen the child's visitors for indications of infection. A- It is not necessary for the nurse to use surgical asepsis when providing direct care. Strict hand washing and medical asepsis are recommended to prevent the spread of infection. B- It is contraindicated for a child who is severely immunocompromised to receive the MMR vaccine because it is a live virus vaccine and the child may not be able to build adequate antibodies to prevent infection with the organism.