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