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Difficulty: HardPharmacological and Parenteral Therapies

A nurse is closely monitoring a client who is receiving a transfusion of packed red blood cells (PRBCs) through an 18-gauge peripheral intravenous (IV) catheter. Fifteen minutes into the transfusion, the client reports acute shortness of breath, chest tightness, and severe lower back pain. Current vital signs reveal a blood pressure of 82/48 mmHg82/48\text{ mmHg}, a heart rate of 128 bpm128\text{ bpm}, and a temperature of 101.8∘F101.8^\circ\text{F} (38.8∘C38.8^\circ\text{C}). The nurse immediately stops the transfusion. Which of the following is the priority parenteral therapy action for the nurse to take next?

  1. Disconnect the blood administration set at the catheter hub and attach new IV tubing primed with 0.9%0.9\% sodium chloride.Answer
  2. B
    Connect a syringe of 0.9%0.9\% sodium chloride to the injection port closest to the client and flush the line.
  3. C
    Immediately discontinue the 18-gauge IV catheter, apply pressure, and establish a new access site.
  4. D
    Prepare to administer a rapid IV fluid bolus of 5%5\% dextrose in water (D5WD_5W) through the existing blood tubing.

Answer

The correct action is to disconnect the blood administration set at the catheter hub and attach a completely new IV tubing setup primed with 0.9% sodium chloride.
When a client experiences an acute hemolytic transfusion reaction, the infusion must be stopped immediately. However, the client is in hypotensive shock and requires emergency IV fluids and medications. To maintain the patent IV access safely, the nurse must disconnect the blood tubing directly at the catheter hub and attach a completely new, sterile IV tubing set primed with 0.9% sodium chloride. This prevents any of the incompatible blood remaining in the old tubing from entering the client's circulation.

Step-by-Step Solution

1
Recognize the clinical presentation.
The combination of acute shortness of breath, severe lower back pain, hypotension, and fever shortly after initiating a transfusion indicates an acute hemolytic transfusion reaction.
Identifying the life-threatening nature of the reaction dictates the urgency of the response.
2
Identify the immediate life-saving intervention.
The nurse correctly stopped the transfusion as the first action.
Stopping the infusion prevents further exposure to the incompatible antigen.
3
Determine the next priority for parenteral management.
The client is in hypotensive shock (82/48 mmHg82/48\text{ mmHg}) and requires immediate IV fluid resuscitation and potentially vasopressors, necessitating patent IV access.
Maintaining the existing large-bore access is critical for survival.
4
Select the safest method to maintain IV access.
Disconnect the existing blood tubing directly at the hub and attach a new, sterile line primed with normal saline.
This preserves the IV site while ensuring none of the incompatible blood remaining in the old tubing is inadvertently pushed into the client's systemic circulation.

Key Concept

Management of an acute hemolytic transfusion reaction requires immediately stopping the infusion and changing the entire IV tubing setup at the hub to maintain circulatory access for emergency resuscitation without bolusing the remaining incompatible blood.
Estimated Time:1m 15s
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Topics

Pharmacological and Parenteral Therapies

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