Điều dưỡng theo dõi một bệnh nhân đang truyền infliximab. Những phát hiện nào cần theo dõi ngay lập tức? Đánh dấu các phát hiện cho thấy phản ứng truyền cấp tính có khả năng nghiêm trọng.

Nurses' Notes 1000: The client begins a scheduled infliximab infusion after the nurse verifies the prescription and emergency supplies. At baseline, the client's temperature remains 36.8 °C without chills or malaise. The record confirms that tuberculosis screening was negative before biologic therapy began. At 1015, the client reports that new chest tightness and audible wheezing begin during the infusion. The nurse notes that the peripheral intravenous site remains soft and free of redness. The pump display shows that the programmed rate matches the current infusion prescription. At 1020, the client says, “I suddenly feel faint.” The monitor shows that blood pressure decreases from 128/76 to 86/52 with dizziness. The pulse oximeter shows that oxygen saturation remains 97% on room air. The client then develops spreading hives across the neck with new swelling of both lips. A prior note states that mild fatigue was present before the medication arrived. The nurse stops the infusion and begins an immediate airway and circulation assessment. The rapid-response medications and provider notification are initiated according to the infusion-reaction protocol.