A nurse in a provider's office is assessing an adolescent who has been taking ibuprofen for 6 months to treat juvenile idiopathic arthritis. Which of the following questions should the nurse ask to assess for an adverse effect of this medication?

Choice A reason:

Administer epinephrine subcutaneously. This is not the necessary action to be taken. Epinephrine is used to treat severe allergic reactions (anaphylaxis). However, in this case, the client is experiencing a febrile non-haemolytic transfusion reaction, not an allergic reaction.

Choice B reason:

Place the blood bag in a biohazard bag before discarding. This is not the necessary action to be taken by the nurse. Proper disposal of biohazardous materials is essential, but in this situation, the nurse's priority is to address the client's condition and not the disposal of the blood bag.

Choice C reason:

Documentation of the transfusion reaction is crucial for the client's medical history and for future reference. The nurse should record the client's signs and symptoms, the actions taken, and any other relevant information related to the reaction.

Choice D reason

Infuse 500 ml lactated Ringer's IV.This is not necessary action to be taken by the nurse because there is no indication for infusing lactated Ringer's solution in response to the transfusion reaction described. Treatment for febrile non-haemolytic transfusion reactions generally involves stopping the transfusion, administering antipyretics (like acetaminophen) if necessary, and providing supportive care as needed.

a. Administer the medication and alert the charge nurse: This choice suggests proceeding with medication administration but also informing the charge nurse. While it's important to communicate with the charge nurse regarding medication administration, in this scenario, there is no indication to hold the medication as the infant's heart rate is within the normal range. Therefore, alerting the charge nurse may not be necessary at this point.

b. Hold the medication and document cardiac assessment: This choice suggests holding the medication and documenting the cardiac assessment. However, since the infant's heart rate is within the normal range for their age, there is no clinical indication to hold the medication. Holding the medication unnecessarily could delay treatment and potentially lead to adverse outcomes if the medication is needed.

c. Administer the medication and document the heart rate.

Since the infant's heart rate of 120 beats per minute falls within the normal range for a 2-month-old, there is no indication to hold the medication. Administering the digoxin as prescribed and documenting the heart rate before administration are appropriate actions. It's important to ensure accurate documentation to track the infant's response to the medication and monitor for any changes in heart rate.

d. Hold the medication and recheck the heart rate in 1 hour: This choice suggests holding the medication and rechecking the heart rate in 1 hour. Again, since the infant's heart rate is within the normal range, there is no clinical indication to hold the medication or delay treatment. Rechecking the heart rate in 1 hour would be unnecessary and could potentially delay necessary medication administration.