Which of the following is a correct description of the site assessment during transfusion?

• A. Temperature only
• B. Blood pressure only
• C. Infiltration, phlebitis, irritation
• D. None

Answer: (C)

The key idea is to evaluate the IV access for local problems that can arise during a transfusion. A proper site assessment looks for signs that the catheter is not in the vein or is causing tissue irritation. Infiltration is when IV fluids leak into the surrounding tissue, causing swelling, pallor or cool skin, and possibly a tight feeling. Phlebitis shows up as redness along the vein, warmth, tenderness, and sometimes a palpable cord. Irritation refers to patient complaints like itching or burning at the insertion site. Detecting these issues early helps prevent tissue injury and ensures the IV is functioning properly. Temperature or blood pressure checks assess overall systemic status, not the specific IV site, so they don’t describe the necessary local surveillance. If any infiltration, phlebitis, or irritation signs appear, follow protocol to stop the transfusion and address the site (e.g., remove and replace the catheter, restart a new IV) to protect the patient.