A nurse is monitoring a client who is receiving a continuous intravenous infusion of packed red blood cells (PRBCs). Fifteen minutes after the transfusion begins, the client reports sudden lower back pain, chills, and dyspnea. Place the following nursing actions in the correct order of performance. (All steps must be used).
- 1Stop the blood transfusion immediately.
- 2Replace the intravenous tubing with a new set primed with 0.9% sodium chloride.
- 3Assess the client's vital signs and oxygen saturation.
- 4Notify the primary healthcare provider and the blood bank.
- 5Return the blood bag and attached tubing to the blood bank.
Answer
1. Stop the blood transfusion immediately. 2. Replace the intravenous tubing with a new set primed with 0.9% sodium chloride. 3. Assess the client's vital signs and oxygen saturation. 4. Notify the primary healthcare provider and the blood bank. 5. Return the blood bag and attached tubing to the blood bank.
In a suspected blood transfusion reaction, the priority is to stop the causative agent immediately to minimize harm. Next, IV access must be maintained with normal saline using completely new tubing to avoid flushing residual blood into the client. Assessment of vital signs follows to determine the client's physiological status, which is then reported to the provider. Finally, the blood products and equipment are returned to the blood bank for investigation.
Step-by-Step Solution
Key Concept
Management of Acute Hemolytic Transfusion Reactions