What nursing action is indicated when a child receiving a unit of ...

[ishan]

What nursing action is indicated when a child receiving a unit of packed red blood cells complains of chills, headache, and nausea?
 
  a. Continue the infusion and take the child's vital signs.
  b. Stop the infusion immediately and notify the physician.
  c. Slow the infusion and assess for cessation of symptoms.
  d. Start a dextrose solution and stay with the child.

Question 2

The nurse administering an IV piggyback medication to a preschool child should take which action?
 
  a. Dilute the medication in at least 20 milliliters and infuse over at least 15 minutes.
  b. Flush the IV tubing before and after the infusion with normal saline solution.
  c. Inject the medication into the IV catheter using the port closest to the child.
  d. Inject the medication into the IV tubing in the direction away from the child.

[mammy1697]

Answer to Question 1

B
If a reaction is suspected, as in this case, the transfusion is stopped immediately and the physician is notified. If the child is displaying signs of a transfusion reaction, the transfusion cannot continue. Dextrose solutions are never infused with blood products because the dextrose causes hemolysis. This action does not address the blood infusion.

Answer to Question 2

A
Medications given by IV piggyback are diluted in at least 20 milliliters of IV solution and administered over at least 15 minutes. When administering medications by IV piggyback, the nurse flushes the tubing after the medication has infused, usually with 16 to 20 milliliters of IV solution. The nurse is using the IV push method when injecting medication into the IV tubing using the port closest to the child. The IV retrograde method involves clamping the IV tubing below the injection port and injecting medication into the tubing in a direction away from the child, causing it to flow into the tubing above the injection port.