A nurse on a pediatric unit is caring for a toddler who has poor dietary intake. Which of the following actions should the nurse take first?

A) *Restrict your daily fluid intake: Restricting fluid intake is not recommended for a client experiencing lightheadedness upon standing, especially when taking an ACE inhibitor. In fact, maintaining adequate hydration is important to help prevent hypotension, which could be exacerbated by fluid restriction. The lightheadedness may be due to orthostatic hypotension, which is a common side effect of ACE inhibitors.

B) *Take a daily potassium supplement: ACE inhibitors can increase potassium levels in the blood, potentially leading to hyperkalemia. For most clients, taking a potassium supplement is not necessary unless specified by the healthcare provider. In fact, many clients taking ACE inhibitors need to avoid excessive potassium intake, unless directed otherwise, to prevent dangerous potassium levels.

C) *Discontinue this medication if this occurs again: The nurse should not advise the client to discontinue the medication without consulting the healthcare provider. Lightheadedness upon standing is a common side effect of ACE inhibitors due to their blood pressure-lowering effects, and the healthcare provider should be notified if this becomes problematic. The decision to change or discontinue the medication should be made by the provider.

D) "Sit back down for a few minutes when this occurs": This is the most appropriate advice. Lightheadedness upon standing can be a sign of orthostatic hypotension, which is a known side effect of ACE inhibitors. The client should be instructed to sit down and rest when they experience these symptoms. If necessary, they should stand up slowly to allow their body to adjust to changes in position, which can help alleviate the lightheadedness.

B. Ensure two nurses confirm the information on the blood label: Before initiating a blood transfusion, two nurses must verify the client’s identity, blood type, and compatibility with the donor blood. This step is essential to prevent transfusion reactions due to mismatched blood.

C. Obtain a large-bore IV catheter: A large-bore IV catheter (18–20 gauge) is necessary to facilitate the transfusion of packed red blood cells (PRBCs). A smaller gauge may cause hemolysis or delay administration.

D. Witness the client signing a consent for transfusion: A blood transfusion is an invasive procedure requiring informed consent. The nurse ensures the client understands the risks, benefits, and potential complications before signing the consent form.

Incorrect Options:

A. Explain to the client that transfusion reactions are not serious: This is incorrect because transfusion reactions can range from mild allergic responses to life-threatening anaphylaxis or hemolytic reactions. The nurse should educate the client on symptoms to report, such as fever, chills, or dyspnea.

E. Ensure the transfusion tubing is flushed with dextrose 5% in water: Blood products should only be administered with 0.9% sodium chloride to prevent hemolysis. Using dextrose solutions can cause red blood cell aggregation and clot formation.