A practical nurse (PN) is monitoring a client who is receiving a packed red blood cell (PRBC) transfusion. Fifteen minutes into the infusion, the client suddenly reports severe lower back pain, chills, and difficulty breathing. In which order should the PN perform the following actions? (Arrange the actions from first to last.)
- 1Stop the blood transfusion immediately.
- 2Disconnect the blood administration set and initiate a normal saline infusion using new intravenous (IV) tubing.
- 3Notify the registered nurse (RN) and the healthcare provider of the suspected reaction.
- 4Obtain a complete set of vital signs and closely monitor the client's respiratory status.
Answer
The correct sequence is to first stop the blood transfusion immediately, followed by initiating a normal saline infusion using new IV tubing. Next, the PN must notify the RN and healthcare provider, and finally, obtain a complete set of vital signs.
In any acute transfusion reaction, the primary goal is to limit the client's exposure to the offending antigen. Therefore, stopping the transfusion is the immediate first step. Venous access must be maintained to administer emergency drugs, but it must be done with entirely new tubing to prevent infusing residual blood. Once the immediate danger is halted and the line is secured, the PN must escalate the situation by notifying the RN and provider. Finally, obtaining vital signs provides essential data for the provider to direct further care.
Step-by-Step Solution
Key Concept
Management of Acute Hemolytic Transfusion Reactions