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 prepares to take action based on the 1855 nursing note entry
➢ Complete the sentences below from the list of the options
The nurse should initially [discontinue the blood transfusion. / obtain assistance from another nurse / pause the transfusion and remove the peripheral vascular access device. / pause the transfusion and contact the physician] Once this is done, the nurse should then [start a new peripheral vascular access device and resume the transfusion. / send the unit of blood and tubing to the blood bank. / verify the client's blood type with the unit of blood being transfused. / request an order for diphenhydramine.]
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