Examkin

Question

Difficulty: HardPhysiological Adaptation

A practical nurse (PN) is monitoring a client who is receiving a transfusion of packed red blood cells. Fifteen minutes into the transfusion, the client reports sudden lower back pain, chills, and dyspnea. Place the following nursing actions in the correct order of priority.

  1. 1Stop the blood transfusion immediately.
  2. 2Initiate an infusion of 0.9% sodium chloride using new intravenous tubing.
  3. 3Obtain a full set of vital signs and assess the client's respiratory status.
  4. 4Notify the charge nurse and the prescribing healthcare provider.
  5. 5Prepare to return the blood bag, tags, and administration set to the blood bank.

Answer

1. Stop the blood transfusion immediately. 2. Initiate an infusion of 0.9% sodium chloride using new intravenous tubing. 3. Obtain a full set of vital signs and assess the client's respiratory status. 4. Notify the charge nurse and the prescribing healthcare provider. 5. Prepare to return the blood bag, tags, and administration set to the blood bank.
In the event of a suspected blood transfusion reaction, the absolute first priority is to stop the transfusion to prevent further administration of incompatible blood. The second step is to maintain a patent IV line for emergency medications and fluid resuscitation; this must be done with 0.9% sodium chloride and completely new tubing to avoid pushing remaining blood from the old tubing into the client. Once the source of harm is stopped and access is secured, the nurse must assess the client's vital signs and respiratory status to gather data. This clinical data is then immediately reported to the charge nurse and healthcare provider. Finally, as a follow-up administrative and diagnostic measure, the remaining blood, tags, and tubing are sent to the blood bank for investigation.

Step-by-Step Solution

1
Recognize the signs of a severe adverse therapy response.
The client is experiencing a potential acute hemolytic transfusion reaction, indicated by lower back pain, chills, and dyspnea.
Early recognition dictates the immediate cessation of the offending agent.
2
Prioritize direct interventions based on removing the source of harm and supporting circulation.
Stopping the transfusion prevents further exposure. Starting normal saline with completely new tubing maintains hemodynamic stability without pushing more blood into the client.
Client safety is the highest priority; flushing the old tubing would actively harm the client.
3
Gather specific clinical data before escalating communication.
Vital signs and respiratory assessment provide a precise baseline of the client's compromised state.
The healthcare provider requires current, objective data to prescribe appropriate emergency pharmacological interventions.
4
Escalate the situation and perform required administrative follow-up.
The charge nurse and provider are notified, and the blood materials are prepared for the blood bank.
Interprofessional communication ensures timely medical intervention, and the blood bank must investigate the cause of the transfusion reaction.

Key Concept

Prioritization of nursing interventions during an acute blood transfusion reaction
Rate this question

Topics

Physiological Adaptation

More questions from this topic