A nurse is preparing to administer packed RBCs to a client with Hgb 8 g/dL. Which action should be performed during the first 15 minutes of the transfusion?

• A. Obtain consent from the client for the transfusion.
• B. Assess for an acute hemolytic reaction.
• C. Explain the transfusion procedure to the client.
• D. Obtain blood culture specimens to send to the lab

Answer: (B)

The key concept is monitoring for an acute hemolytic transfusion reaction during the initial infusion. The first 15 minutes after starting a packed RBC transfusion is the period when an ABO incompatibility can produce a severe reaction, so the nurse must be with the patient and vigilantly observe for signs. Look for fever, chills, back or flank pain, flushing, shortness of breath, chest tightness, hypotension, or a rapid pulse. If any of these occur, the transfusion should be stopped immediately, the IV line kept open with normal saline, and the clinician and blood bank alerted so diagnostic workup can begin and urgent treatment can be provided. This rapid response to potential reaction is essential because it can escalate quickly and become life-threatening. Pretransfusion steps like obtaining consent or explaining the procedure are completed before the infusion starts, and obtaining cultures is not part of the immediate transfusion safety checks during the first 15 minutes; those tasks relate to other phases of care and testing, not the urgent reaction assessment at this moment.