A hospitalized child is receiving antithymocyte globulin (ATG) for aplastic anemia. What action by the nurse is most important?
A.
Assess the IV site for good blood return.
B.
Ensure emergency equipment is nearby.
C.
Obtain informed consent for each dose.
D.
Pad side rails and institute seizure precautions.
ANS: B
ATG is made from horse or rabbit serum and can cause anaphylaxis, even after test dosing. The nurse ensures that appropriate emergency equipment is available in case of such an emergency. Assessing the IV site is also an important action, but does not take priority over being prepared for an emergency. Informed consent is not required for each dose. Seizure precautions are not needed.
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