A practical nurse is monitoring a client who began receiving a packed red blood cell (PRBC) transfusion 15 minutes ago. The client suddenly reports acute lower back pain, chills, and shortness of breath. To reduce the risk of further complications, arrange the following nursing actions in the correct priority order.
- 1Stop the blood transfusion immediately.
- 2Disconnect the blood tubing and attach a new normal saline infusion line.
- 3Notify the registered nurse (RN) and the healthcare provider.
- 4Obtain a complete set of vital signs and monitor urinary output.
- 5Return the discontinued blood bag and tubing to the blood bank.
Answer
The correct priority sequence is to first stop the transfusion, then initiate a normal saline infusion with new tubing, notify the RN and provider, obtain vital signs, and finally return the blood products to the blood bank.
In the event of a suspected hemolytic transfusion reaction, nursing priorities focus on immediately halting the antigen exposure and maintaining venous access for emergency medications. Stopping the transfusion is universally the first step. Next, the line must be kept open with 0.9% sodium chloride, crucially using completely new tubing to avoid infusing the blood left in the original line. Once the immediate source of harm is stopped and access is secured, the nurse escalates to the RN and provider. Assessing vital signs and monitoring urine output follows to detect shock or renal failure. Finally, administrative and diagnostic steps, such as sending the blood bag to the lab, are completed after client stabilization.
Step-by-Step Solution
Key Concept
Reduction of Risk Potential: Emergency Management of Blood Transfusion Reactions