Difficulty: Medium
Average Score: 72%
Simulated
Passage / Scenario
The following scenario applies to the next 1 itemsThe nurse is assessing a client receiving a transfusion of packed red blood cells.
Item 1 of 1
Nurses' Notes
1800: Prescribed PRBC infusion started. Client was educated to notify the RN of any
manifestations regarding a transfusion reaction. Pretransfusion vital signs were obtained: T 98┬░ F (36.7┬░ C), P 62, RR 18, BP 130/86, pulse oximetry reading 98% on room air.
1815: Client reports no manifestations of a transfusion-related reaction. Denies any headache, nausea, chills, or backache. Vital signs: T 98.4┬░ F (36.9┬░ C), P 69, RR 17, BP 128/83, pulse oximetry reading 98% on room air.
1855: Client alerted the nurse that "something is wrong with my IV." On assessment, the client reported pain at the peripheral vascular access device as a 5/10 on the Numerical Rating Scale. Swelling was observed at the vascular access insertion site.
The nurse should initially ├óÔé¼┬ª├óÔé¼┬ª├óÔé¼┬ª├óÔé¼┬ª.. Once this is done, the nurse should then ├óÔé¼┬ª├óÔé¼┬ª├óÔé¼┬ª.. for a client receiving a transfusion of packed red blood cells with pain and swelling at the IV site.
Correct answer
C,E
Rationale
Pain and swelling suggest infiltration or extravasation. Pausing the transfusion and removing the IV device is the initial step, followed by starting a new IV site to safely resume the transfusion.