Difficulty: Medium
Average Score: 74%
Simulated
A nurse is caring for a client who has a prescription for one unit of packed RBCs. The nurse should plan to remain in the room with the client at which of the following times during the infusion to observe for a transfusion reaction?
Correct answer
C
Rationale
The correct answer is C: The first 15 min. This is because transfusion reactions typically occur within the first 15 minutes of starting a blood transfusion. The nurse needs to closely monitor the client during this critical period to promptly identify and manage any adverse reactions. Remaining in the room during this time allows for immediate assessment and intervention if necessary.
Choice A: The final 2 min is incorrect because by this time, any potential reaction would have likely already occurred and the client may be stable.
Choice B: The final 15 min is also incorrect as reactions are more likely to happen earlier in the infusion process.
Choice D: The first 2 min is too short a time frame to adequately monitor for potential reactions, as some reactions may take longer to manifest.
In summary, the correct answer is C as it aligns with best practice guidelines for monitoring transfusion reactions and ensuring client safety.
Choice A: The final 2 min is incorrect because by this time, any potential reaction would have likely already occurred and the client may be stable.
Choice B: The final 15 min is also incorrect as reactions are more likely to happen earlier in the infusion process.
Choice D: The first 2 min is too short a time frame to adequately monitor for potential reactions, as some reactions may take longer to manifest.
In summary, the correct answer is C as it aligns with best practice guidelines for monitoring transfusion reactions and ensuring client safety.