A practical nurse (PN) is monitoring a client who is receiving a continuous infusion of packed red blood cells (PRBCs). Fifteen minutes after the transfusion begins, the client suddenly reports severe lower back pain, chills, and shortness of breath. Arrange the PN's interventions in the correct order of priority.
- 1Stop the blood transfusion immediately.
- 2Disconnect the blood tubing and connect a new tubing primed with 0.9% normal saline.
- 3Notify the supervising registered nurse (RN).
- 4Assess the client's vital signs and respiratory status.
- 5Return the blood bag, tubing, and attached labels to the blood bank.
Answer
The correct priority sequence for a suspected hemolytic transfusion reaction is to first stop the transfusion, secure the IV line with normal saline using new tubing, notify the supervising RN, assess vital signs, and finally send the blood product to the blood bank.
In the event of a blood transfusion reaction, the immediate priority is to stop the cause of the reaction (following Airway, Breathing, Circulation principles by stopping the harmful agent first). Next, IV access must be maintained for potential emergency drug administration, which requires entirely new tubing primed with normal saline. Following this, the PN must notify the RN to escalate the emergency. Assessing vital signs is the next priority to monitor for shock and respiratory distress. Finally, administrative and diagnostic steps, such as returning the blood to the lab, are completed.
Step-by-Step Solution
Key Concept
Management of acute blood transfusion reactions.
Estimated Time:1m 30s