NCLEX PN Exam Practice Test Practice Question
A blood transfusion has just been started on an adult. Which assessment is most essential during the first hour?
Correct Answer: A
Rationale: Monitoring temperature is crucial during the first hour of a blood transfusion, as it helps detect potential transfusion reactions, such as febrile non-hemolytic reactions, which can occur early. Elevated temperature may indicate an adverse response, necessitating immediate intervention.
While blood pressure, respirations, and pulse are important assessments, they are secondary in this context. Blood pressure changes may indicate a reaction but are less immediate than temperature. Respiratory assessment is vital but typically follows temperature monitoring, and pulse changes can occur later in the transfusion process. Prioritizing temperature ensures timely identification of complications.
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