A nurse is caring for a client who is receiving a unit of packed red blood cells (PRBCs). Fifteen minutes after the transfusion is initiated, the client suddenly reports severe lower back pain, chills, and dyspnea. Place the following nursing interventions in the correct order of priority from first to last.
- 1Stop the blood transfusion immediately.
- 2Disconnect the blood tubing and maintain IV access with normal saline using new tubing.
- 3Assess the client's vital signs and cardiopulmonary status.
- 4Notify the healthcare provider and the blood bank.
- 5Return the blood bag, attached tubing, and labels to the blood bank.
Answer
The correct sequence is to first stop the transfusion, then maintain IV access with normal saline using new tubing, followed by assessing the client, notifying the provider and blood bank, and finally returning the blood bag and tubing to the blood bank.
The absolute priority during any suspected acute transfusion reaction is to stop the infusion to prevent further harm. Once stopped, the nurse must preserve intravenous access using new tubing to ensure emergency medications can be given without pushing residual incompatible blood into the client. After securing access, a rapid physiological assessment provides the necessary data to report when notifying the healthcare provider. Finally, once the client is being managed, the equipment must be sent for laboratory analysis.
Step-by-Step Solution
Key Concept
Prioritization of care during a suspected acute hemolytic blood transfusion reaction