A nurse has begun an infusion of intravenous immunoglobulin (IVIG) to a child who has combined immunodeficiency disease. The infusion should be stopped if the child:
1. Experiences a mild headache.
2. Voids clear yellow urine.
3. Develops severe shaking, chills, and fever.
4. Complains of being thirsty.
3
Rationale:
1. A mild headache is an adverse side effect of IVIG but not a severe reaction.
2. Voiding clear yellow urine is a normal finding.
3. Hypersensitivity reaction can be seen with IVIG. The infusion should be started slowly and increased if there is no reaction. Shaking, chills, and fever can indicate a reaction.
4. Thirst is not an indication of a reaction.
You might also like to view...
When the patella is tapped with a reflex hammer, a patient demonstrates a sluggish response. The lack of reflex response may be an indicator of:
A) Peripheral nerve damage. B) Muscle impairment. C) Neurotransmitter deficiency. D) All of the above.
Which patient statement on cultural or religious influences on nutrition requires intervention by the nurse?
1. "My grandmother makes sure I eat a serving of greens each day." 2. "I avoid milk and meat together at meals because I am Jewish." 3. "My auntie sent me clay from the South to eat every day." 4. "Because I am Muslim, I do not ever eat any pork products."
An accident or violent act that causes injury is:
a. Shock b. A wound c. Trauma d. Inflammation
What is the belief regarding twins who adopt dramatically different lifestyles?
a. They may experience very different aging processes. b. They will retain very similar methylation patterns. c. They will experience identical phenotypes throughout their lifespans. d. They may never demonstrate similar DNA sequences of their somatic cells.