HESI RN EXIT EXAM 2021 – [STUDY GUIDE]
1. The nurse assesses a client one hour after starting a transfusion of packed RBC and determines that there are no indicators of a transfusion reaction. What instruction should the nurse provide the unlicensed assistive personnel UAP who is working with the nurse?
a. Notify the nurse when the transfusion has finished, so further client assessment can be done
b. Monitor the client carefully for the next three hours and report the onset of the reaction immediately
c. Continue to measure the client’s vital signs every thirty minutes until transfusion is complete
d. Since a reaction did not occur, the priority is to maintain client comfort during the transfusion
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