# The nurse monitors a client receiving infliximab. Which findings require immediate follow-up? Highlight the findings that indicate a potentially serious acute infusion reaction. > source: MyMerci (mymerci.kr) > url: https://mymerci.kr/pages/nclex_q.php?qn_id=497300&lang=en > language: en > subject: Medication Administration > category: PPT ## Question The nurse monitors a client receiving infliximab. Which findings require immediate follow-up? Highlight the findings that indicate a potentially serious acute infusion reaction. 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. ## Explanation New wheezing, a symptomatic blood-pressure decrease, and facial hives with swelling require immediate follow-up. These findings can signal a severe infusion reaction requiring interruption, airway assessment, and rapid treatment. ## In-depth explanation Quick answer Highlight new chest tightness with wheezing, the blood-pressure decrease with dizziness, and spreading hives with lip swelling. Stop the infusion, maintain access with compatible fluid per protocol, assess airway and circulation, and activate prescribed emergency treatment. Why this is correct Infliximab can cause serious infusion reactions, including dyspnea, hypotension, urticaria, and anaphylaxis. New airway symptoms, circulatory compromise, or angioedema during the infusion is more urgent than stable baseline findings and requires prompt interruption and evaluation.[2] Easy analogy or mental picture Imagine an alarm panel with breathing, pressure, and swelling lights. When any of those lights turns on during an infusion, pause the incoming drug and assess the client; the image supports recognition but does not grade reaction severity. Memory hook Wheeze, pressure drop, swelling: stop and assess. NCLEX decision rule During a medication infusion, prioritize new airway, breathing, circulation, and rapidly progressing allergic findings over stable screening results or expected minor discomforts. Why the other choices are wrong A negative tuberculosis screen, a patent intravenous site, an unchanged temperature, stable oxygen saturation, and a correctly programmed pump support safe administration. Mild preexisting fatigue without progression does not by itself identify an acute hypersensitivity reaction.References - [1]NCSBN: 2026 NCLEX-RN Test PlanNational Council of State Boards of Nursing - [2]DailyMed: Infliximab Prescribing InformationU.S. National Library of Medicine ## Related questions - [Before giving a scheduled dose of digoxin, the nurse obtains an apical pulse of 54/min in …](https://mymerci.kr/pages/nclex_q.php?qn_id=374883&lang=en) - [An older adult taking digoxin reports nausea, poor appetite, and yellow-green halos. 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