During the initial phase of a blood product transfusion, what is the recommended nursing action?

• A. Stay with client during the first 15 minutes of infusion.
• B. Flush with saline during the first minute.
• C. Begin rapid infusion immediately.
• D. Infuse through a central line only within the first hour

Answer: (A)

The key idea here is close monitoring during the first phase of a blood transfusion. Most transfusion reactions occur early, so staying with the patient during the initial 15 minutes allows you to notice any clues quickly—fever, chills, itching, back or chest pain, shortness of breath, or sudden changes in breathing or blood pressure. By watching closely and stopping the transfusion at the first sign of a reaction, you prevent worsening harm and can initiate appropriate interventions immediately. If the patient tolerates this initial period, you can continue the infusion at a safe pace with ongoing monitoring.

For context, starting the transfusion at a slow rate during this first interval provides a window to detect intolerance before a large volume is infused. While ongoing monitoring continues after the initial phase, the priority is having a trained nurse at the bedside to respond promptly if a reaction develops.