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Difficulty: EasyPharmacological and Parenteral Therapies

Fifteen minutes after the initiation of a packed red blood cell (PRBC) transfusion, a client reports sudden severe lower back pain and develops chills. Which action must the nurse take first?

  1. Stop the transfusion immediately and keep the vein open with normal saline.Answer
  2. B
    Slow the infusion rate and contact the healthcare provider for further prescriptions.
  3. C
    Administer a prescribed as-needed dose of acetaminophen to manage the chills.
  4. D
    Complete a full set of vital signs and auscultate the client's lung fields.

Answer

The nurse must immediately stop the blood transfusion and maintain intravenous access with normal saline.
Severe lower back pain and sudden chills shortly after starting a blood transfusion are hallmark signs of an acute hemolytic reaction. The absolute highest priority is to stop the infusion of the incompatible blood immediately to prevent further physiological harm. Maintaining the IV line with normal saline is the critical next step to keep venous access open for emergency interventions and to flush the line without pushing more blood into the client.

Step-by-Step Solution

1
Identify the client's symptoms.
The lower back pain and sudden chills indicate a high probability of an acute hemolytic transfusion reaction.
Recognizing adverse reactions to parenteral therapies is the first step in clinical judgment.
2
Determine the highest priority intervention to prevent harm.
The immediate cessation of the blood product is chosen as the priority.
Continuing the transfusion, even at a slower rate or while gathering more assessment data, will infuse more incompatible cells and worsen the life-threatening condition.
3
Maintain the intravenous access.
Sterile normal saline is infused through the IV line.
The client will likely need emergency medications, fluid resuscitation, and blood pressure support, making a patent IV line critical.

Key Concept

Management of Acute Hemolytic Transfusion Reactions
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Topics

Pharmacological and Parenteral Therapies

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