A client is admitted to the emergency department with an active upper gastrointestinal bleed. The client's vital signs are blood pressure 84/52 mmHg, heart rate 126 beats per minute, and respiratory rate 22 breaths per minute. The client has a single 18-gauge peripheral intravenous catheter currently infusing 5% dextrose in water (D5W) at 100 mL/hr. The healthcare provider prescribes a stat transfusion of one unit of packed red blood cells (PRBCs) and intravenous pantoprazole. Which action should the nurse take first?
- Discontinue the 5% dextrose in water infusion, flush the catheter with 0.9% sodium chloride, and begin the transfusion.Answer
- BConnect the packed red blood cell administration set to the lowest Y-site port of the existing 5% dextrose in water infusion.
- CDelegate the continuous monitoring of the client's vital signs for the first 15 minutes of the transfusion to the unlicensed assistive personnel.
- DAdminister the prescribed intravenous pantoprazole immediately to address the active source of the gastrointestinal bleeding.
Answer
The nurse should discontinue the 5% dextrose in water infusion, flush the intravenous catheter with 0.9% sodium chloride, and initiate the packed red blood cell transfusion.
The client is exhibiting signs of hypovolemic shock (hypotension, tachycardia) due to acute blood loss. The priority based on the ABC (Airway, Breathing, Circulation) framework is to restore intravascular volume and oxygen-carrying capacity. Because blood products are strictly incompatible with 5% dextrose in water (which causes hemolysis), the nurse must stop the incompatible infusion and flush the line with 0.9% sodium chloride before initiating the transfusion.
Step-by-Step Solution
Key Concept
Blood products must only be administered with 0.9% sodium chloride to prevent hemolysis. Furthermore, restoring circulating volume is the highest priority for a client in active hypovolemic shock.