The nurse initiates a blood transfusion for a client. What action should the nurse take next?
1. Stay with the client and closely observe him for the first 5 to 10 minutes of the transfusion.
2. Assign the UAP to sit with the client for 15 minutes.
3. Advise the client to notify the nurse if he experiences any chilling, nausea, flushing, or rapid heart rate.
4. Return to the room and take a set of vital signs in 15 minutes.
Correct Answer: 1
Rationale 1: The nurse should stay with the client and closely observe him for the first 5 to 10 minutes of the transfusion.
Rationale 2: The nurse cannot delegate this assessment to the UAP.
Rationale 3: The client should be advised of reactions to report, but this self-reporting is more indicated after the nurse is no longer in constant attendance.
Rationale 4: The nurse should stay with the client and closely observe him for the first 5 to 10 minutes of the transfusion. The nurse cannot delegate this assessment to the UAP.
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