How long should a nurse plan to remain with a client to observe for a transfusion reaction after starting packed RBCs?

Monitoring a client after the initiation of a packed red blood cell (RBC) transfusion is crucial for early detection of any transfusion reactions, which can be severe and require immediate intervention. The correct duration for nursing observation is the first 15 minutes after starting the transfusion.

During this initial period, the body is most likely to show signs of an adverse reaction, which can include symptoms such as fever, chills, itching, or dyspnea. This timeframe is essential because many acute transfusion reactions manifest within the first few minutes to the first 30 minutes of the transfusion. By remaining with the client for this duration, the nurse can quickly identify any negative responses and initiate appropriate medical responses, such as stopping the transfusion or administering medications.

In contrast, observing only during the first 2 minutes may not provide enough time for reactions to become evident, limiting the ability to intervene effectively. Observing in the final 2 or final 15 minutes of the transfusion does not address the critical early monitoring phase where reactions are most likely to occur. Therefore, the focus on the first 15 minutes ensures that the client is closely monitored when they are most vulnerable to complications.