A nurse is caring for a client who is receiving a packed red blood cell (PRBC) transfusion. Fifteen minutes after the transfusion begins, the client reports sudden chills and lower back pain. In what order should the nurse perform the following actions to minimize the client's risk of further injury? Arrange the steps from first to last.
- 1Stop the blood transfusion.
- 2Disconnect the blood tubing and connect a new infusion of 0.9% sodium chloride.
- 3Assess the client's vital signs and respiratory status.
- 4Notify the healthcare provider and the blood bank.
- 5Return the blood bag and attached tubing to the blood bank.
Answer
The correct sequence is: Stop the transfusion, initiate a normal saline infusion with new tubing, assess vital signs, notify the provider and blood bank, and return the blood bag to the blood bank.
When a client exhibits signs of a blood transfusion reaction (such as sudden chills and lower back pain), the immediate priority is to stop the transfusion to prevent further exposure. Next, the nurse must maintain IV access by infusing normal saline through completely new tubing (to avoid flushing residual blood from the old tubing into the client). With safety measures in place, the nurse then assesses the client's vital signs and respiratory status to determine clinical stability. Following the assessment, the healthcare provider and blood bank are notified so that emergency treatments can be ordered. Finally, the blood bag and tubing are returned to the blood bank for testing.
Step-by-Step Solution
Key Concept
Blood Transfusion Reaction Protocol