A nurse is monitoring a client who is receiving a transfusion of packed red blood cells (PRBCs). Fifteen minutes into the infusion, the client reports sudden, severe lower back pain, chills, and shortness of breath. Arrange the following nursing actions in the correct sequential order of priority to minimize the risk of further physiological deterioration.
- 1Stop the blood transfusion immediately.
- 2Replace the blood tubing with a new administration set and initiate an infusion of normal saline.
- 3Assess the client's vital signs and cardiopulmonary status.
- 4Notify the prescribing healthcare provider and the blood bank about the suspected reaction.
- 5Return the discontinued blood bag and attached tubing to the blood bank.
Answer
The correct sequence of actions is to first stop the transfusion, then replace the tubing and infuse normal saline, followed by assessing the client, notifying the healthcare provider and blood bank, and finally returning the blood bag and tubing to the blood bank.
In any suspected transfusion reaction, the primary goal is to minimize physiological risk. The first and most critical action is to stop the transfusion to prevent further exposure to the offending antigen. The next priority is to maintain a patent IV line with normal saline using new tubing to allow for emergency medication administration while preventing residual blood from entering the client. Once the immediate source of harm is mitigated and access is secured, the nurse must assess the client's current status to gather clinical data. This assessment data is then communicated to the healthcare provider and the blood bank. Finally, sending the blood bag and tubing to the blood bank is done after all immediate client safety and communication needs are met.
Step-by-Step Solution
Key Concept
Prioritization of interventions during an acute hemolytic transfusion reaction to reduce risk of systemic compromise.
Estimated Time:1m 30s