While monitoring a client receiving an infusion of packed red blood cells, the nurse notes the client suddenly develops chills, dyspnea, and flank pain. Arrange the following nursing actions in the correct priority sequence to mitigate further physiological risk.
- 1Stop the blood transfusion immediately.
- 2Disconnect the blood tubing and initiate normal saline with new IV tubing.
- 3Assess the client's vital signs and respiratory status.
- 4Notify the healthcare provider and the blood bank.
- 5Send the blood bag, attached tubing, and labels back to the blood bank.
Answer
The correct sequence is to first stop the transfusion, maintain the IV line with normal saline using new tubing, assess the client, notify the provider and blood bank, and finally return the blood products for testing.
When a hemolytic transfusion reaction is suspected (indicated by chills, dyspnea, and flank pain), the absolute highest priority is stopping the source of harm. Immediately after stopping the transfusion, the nurse must maintain a patent IV line for emergency medications by infusing normal saline through entirely new tubing. Once the client's line is secure, the nurse assesses the client to gather data, notifies the provider to get medical orders, and finally sends the remaining blood products to the lab for investigation. This chronological sequence prioritizes immediate life-saving actions over assessment and reporting.
Step-by-Step Solution
Key Concept
Management of Acute Hemolytic Transfusion Reactions
Estimated Time:1m 0s