A practical nurse is monitoring a client who began receiving a packed red blood cell transfusion 15 minutes ago. The client suddenly reports severe lower back pain, feeling chilled, and shortness of breath. Arrange the following nursing actions in the correct priority order.
- 1Stop the packed red blood cell transfusion immediately.
- 2Replace the blood tubing with a new administration set primed with 0.9% sodium chloride.
- 3Obtain the client's vital signs and assess respiratory effort.
- 4Report the client's symptoms and vital signs to the charge nurse and healthcare provider.
- 5Return the blood bag, tubing, and attached labels to the blood bank.
Answer
The correct priority sequence is: stop the transfusion, replace the tubing with a new set primed with normal saline, obtain vital signs, notify the charge nurse and provider, and finally return the blood products to the blood bank.
In an acute hemolytic transfusion reaction, the immediate priority is to stop the offending agent. Maintaining IV access is the next critical step for emergency fluid resuscitation, but it must be done with new tubing to prevent flushing residual blood into the client. Once the line is secure, the nurse assesses vital signs to determine the severity of the shock, which is then reported to the healthcare provider. Finally, once the client is stable and orders are executed, the blood products are returned to the laboratory for investigation.
Step-by-Step Solution
Key Concept
Prioritization of emergency nursing actions during an acute hemolytic transfusion reaction.