A practical nurse (PN) is assisting with the monitoring of a client who is receiving a packed red blood cell (PRBC) transfusion. The client suddenly reports severe lower back pain, chills, and shortness of breath. Arrange the following nursing actions in the correct sequence of priority to reduce the client's risk of further complications.
- 1Stop the administration of the blood product immediately.
- 2Maintain intravenous access with a new tubing set primed with 0.9% sodium chloride.
- 3Obtain the client's vital signs and complete a focused cardiopulmonary assessment.
- 4Report the assessment findings and suspected reaction to the supervising registered nurse (RN).
- 5Collect required blood and urine specimens to evaluate for potential hemolysis.
Answer
The correct sequence is: Stop the transfusion immediately, maintain IV access with new tubing and 0.9% sodium chloride, assess vital signs and cardiopulmonary status, report findings to the supervising RN, and finally collect required blood and urine specimens.
In any emergency where a therapeutic intervention causes severe harm (such as a hemolytic transfusion reaction), the absolute first priority is to stop the intervention. Following immediate cessation, the nurse must secure the IV line with normal saline using new tubing to prevent further infusion of the blood while keeping the vein open for emergency drugs. Next, the nurse assesses the client to gather critical physiological data, reports these findings to the RN for medical escalation, and finally executes post-reaction protocol steps such as collecting diagnostic specimens.
Step-by-Step Solution
Key Concept
The priority sequence for managing a blood transfusion reaction focuses on immediately removing the risk (stopping blood), maintaining access safely (new tubing), assessing severity, and escalating care.