Which sequence correctly describes vital signs monitoring during a transfusion?

• A. Every 60 minutes throughout.
• B. No monitoring unless symptoms.
• C. Every 15 minutes for two hours.
• D. Every 5 minutes for first 15 minutes, then every 30 minutes for 1 hour, then every hour

Answer: (D)

The main idea is to monitor the patient’s vital signs at intervals that allow rapid detection of any transfusion reaction while the infusion is in progress. The highest risk of acute transfusion reactions is in the first part of the transfusion, so vital signs are checked more frequently early on. The pattern described—vital signs every 5 minutes for the first 15 minutes, then every 30 minutes for the next hour, and then every hour for the remainder—fits this approach. It provides close surveillance during the period when reactions commonly begin, then reduces frequency once the infusion is established and the patient remains stable. Baseline vitals should be obtained before starting, and the nurse should remain alert to signs such as fever, chills, shortness of breath, hypotension, tachycardia, or back/flank pain, which would prompt immediate reassessment. Other monitoring schemes that space checks too far apart or wait for symptoms to appear risk missing an early reaction or deterioration.