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Exam NCLEX-RN topic 1 question 51 discussion

Actual exam question from Test Prep's NCLEX-RN
Question #: 51
Topic #: 1
[All NCLEX-RN Questions]

The child with iron poisoning is given IV deforoxamine mesylate (Desferal). Following administration, the child suffers hypotension, facial flushing, and urticaria.
The initial nursing intervention would be to:

  • A. Discontinue the IV
  • B. Stop the medication, and begin a normal saline infusion
  • C. Take all vital signs, and report to the physician
  • D. Assess urinary output, and if it is 30 mL an hour, maintain current treatment
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Suggested Answer: B 🗳️
(A) The IV line should not be discontinued because other IV medications will be needed. (B) Stop the medication and begin a normal saline infusion. The child is exhibiting signs of an allergic reaction and could go into shock if the medication is not stopped. The line should be kept opened for other medication. (C) Taking vital signs and reporting to the physician is not an adequate intervention because the IV medication continues to flow. (D) Assessing urinary output and, if it is 30 mL an hour, maintaining current treatment is an inappropriate intervention owing to the childs obvious allergic reaction.
by zecks at Oct. 15, 2023, 4 p.m.

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zecks
1 year, 1 month ago
B. Stop the medication ,and start normal saline infusion
upvoted 1 times
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