Question

A nurse is evaluating a client 10 minutes after the administration of 1 unit of packed red blood cells. Which clinical finding will the nurse immediately document in the client's medical record?

The post-transfusion hemoglobin level

The client's weight

The pain level pre-transfusion

The client's vital signs

Answer 1

The nurse should immediately document the client's vital signs after a blood transfusion to monitor for potential adverse reactions.

Step-by-step explanation:

The vital signs of a client are what a nurse should immediately document in the medical record following the administration of 1 unit of packed red blood cells. Monitoring for potential adverse reactions, such as a hemolytic transfusion reaction (HTR), is critical in the period immediately after a blood transfusion. Signs of an HTR can include fever, chills, itching, hives, shortness of breath, and low blood pressure, which can manifest within the first 24 hours post-transfusion, and vital signs can offer the earliest indicators of such a response.

Examples of vital signs that the nurse will document include: Blood pressure (to assess for hypotension or hypertension) Pulse rate (to monitor for any changes in heart rate) Respiratory rate (to monitor for any signs of respiratory distress) Temperature (to monitor for fever or hypothermia)