A nurse is preparing to administer amoxicillin 100 mg PO every 8 hr to a toddler who weighs 20 kg. The recommended dosage range is 20 to 25 mg/kg/day. Which of the following actions by the nurse is appropriate?

A. Lubricating the suction catheter tip with sterile saline is generally not recommended. The catheter tip is usually not lubricated before suctioning. Instead, suctioning should be performed using a dry, sterile catheter to prevent introducing any substances into the airway that could cause irritation or infection.
B. Hyperoxygenating the patient with 100% oxygen before suctioning is a crucial step. This helps to prevent hypoxia during the suctioning procedure, as suctioning can temporarily reduce the oxygen levels in the blood. By providing 100% oxygen for 30 to 60 seconds, the nurse ensures that the patient has an adequate oxygen reserve and reduces the risk of oxygen desaturation during suctioning.
C. Performing chest physiotherapy is not a routine pre-suctioning action and is generally done as part of a separate management strategy for clearing secretions. Chest physiotherapy involves techniques such as percussion, vibration, and postural drainage to help mobilize secretions from the lungs.
D. Instilling normal saline into the airway before suctioning (known as “normal saline lavage”) is not recommended. This practice can actually cause harm, such as increasing the risk of infection, causing bronchospasm, and diluting secretions which may then become more difficult to suction.

A. While administering 0.9% sodium chloride is an important step to maintain venous access and to help dilute any blood that might still be in the tubing, it is not the first action to take if a transfusion reaction is suspected. This step should occur after the transfusion is stopped and the patient’s safety is ensured.
B. The immediate priority when a transfusion reaction is suspected is to stop the transfusion immediately. This action helps to prevent further exposure to the potentially harmful blood product and mitigates the risk of worsening the reaction. Stopping the transfusion also allows for prompt medical assessment and intervention.
C. Returning the unit of blood to the blood bank is important for investigation and to determine the cause of the reaction, but it should be done after stopping the transfusion and ensuring the client’s safety. The blood bank may require the returned unit to confirm any issues with the blood product.

D. Obtaining a blood sample from the client is crucial for diagnostic purposes and to identify the cause of the reaction, but this should be done after the transfusion has been stopped. The sample may help in diagnosing the type of reaction or in managing it, but it does not address the immediate safety concerns.