A nurse is assisting in the care of a client receiving IV fluids. The nurse identifies that the IV pump has been infusing the fluids at double the rate of the prescribed order. After stopping the infusion, which of the following actions is the nurse's priority?

Rationale:

• Document the blood product transfusion in the client’s medical record: It is essential to record the transfusion, including time started and ended, vital signs, and any reactions. Documentation ensures traceability, supports patient safety, and meets regulatory and institutional requirements.

• Monitor the client for the first 15 min of the transfusion: The first 15 minutes are the most critical for detecting transfusion reactions, such as fever, chills, rash, or anaphylaxis. Continuous monitoring during this window allows for prompt intervention if adverse symptoms occur.

• Assist with obtaining the first unit of packed RBCs from the blood bank: RNs or authorized personnel can retrieve blood from the blood bank. Proper handling and timely transport of the blood ensure viability and reduce the risk of hemolysis or temperature-related damage.

• Assist with titrating the rate of infusion to maintain the client’s blood pressure at 90/60 mm Hg or above: Titrating transfusion rates based solely on BP is not within nursing protocol unless specifically ordered. Blood products must be infused according to prescription typically over 2 to 4 hours per unit unless a reaction or complication occurs.

• Start an IV bolus of lactated Ringer’s solution: The provider specifically prescribed a 0.9% sodium chloride bolus. Lactated Ringer’s is contraindicated during transfusions because it contains calcium, which can cause clotting when mixed with blood products.

• Discard the blood bag in the client’s trash can after the transfusion: Blood bags must be disposed of in biohazard containers to comply with infection control policies. Discarding medical waste in general trash violates safety protocols and increases contamination risk.

Rationale:

A. "I'm going to contact your partner for you now.": While involving loved ones can be supportive, taking action without first addressing the client’s emotional state or asking their preference may feel dismissive or intrusive during a vulnerable moment.

B. "Let's talk about the treatment options you were given.": Shifting the focus to treatment too quickly can invalidate the client's immediate emotional response. Emotional support should take precedence over information processing in the early moments of distress.

C. "I'll stay with you for a little while if that's okay.": Offering presence and emotional support communicates compassion and allows the client space to express grief. This response fosters trust and demonstrates empathy without pressuring the client to talk or act.

D. "Your provider will take good care of you.": Though intended to reassure, this response deflects the client’s emotional pain and may come off as impersonal or minimizing. It does not address the need for immediate emotional support.