The nurse is administering an intravenous chemotherapeutic agent to a child with leukemia. The child suddenly begins to wheeze and have severe urticaria. What nursing action is most appropriate to initiate?
a. Recheck the rate of drug infusion.
b. Stop the drug infusion immediately.
c. Observe the child closely for next 10 minutes.
d. Explain to the child that this is an expected side effect.
ANS: B
When an allergic reaction is suspected, the drug is immediately discontinued. Any drug in the line should be withdrawn, and a normal saline infusion begun to keep the line open. The intravenous infusion is stopped to minimize the amount of drug that infuses. The infusion rate can be confirmed at a later time. Observation of the child for 10 minutes is essential, but it is done after the infusion is stopped. These signs are indicative of an allergic reaction, not an expected response.
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