A nurse is caring for a client who is receiving a unit of packed red blood cells. Fifteen minutes into the transfusion, the client reports sudden chills, severe lower back pain, and shortness of breath. Arrange the following nursing interventions in the correct priority sequence from first to last.
- 1Stop the blood transfusion immediately.
- 2Infuse normal saline through a new piece of intravenous tubing.
- 3Assess the client's vital signs and respiratory status.
- 4Notify the primary healthcare provider and the blood bank.
- 5Send the remaining blood product and tubing to the blood bank.
Answer
The correct priority sequence is to stop the transfusion first, maintain IV access with normal saline using new tubing, assess the client's vital signs, notify the provider and blood bank, and finally send the remaining blood and tubing to the blood bank.
In any emergency where a therapeutic intervention causes severe harm (such as a hemolytic transfusion reaction), the absolute first priority is to stop the offending agent. Once stopped, preserving IV access with normal saline and new tubing ensures a route for emergency medications without infusing residual blood. The nurse must then assess the client to gather necessary clinical data before notifying the healthcare provider. Administrative tasks, such as returning the blood bag to the laboratory, are performed only after the client is physiologically stabilized and primary interventions are complete.
Step-by-Step Solution
Key Concept
Management of Acute Hemolytic Transfusion Reaction