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Difficulty: MediumPharmacological and Parenteral Therapies

A nurse is caring for a client who is receiving an intravenous transfusion of packed red blood cells (PRBCs). Fifteen minutes after the transfusion is initiated, the client reports severe lower back pain, chills, and shortness of breath. The nurse assesses a temperature of 38.6∘C38.6^\circ\text{C} (101.5∘F101.5^\circ\text{F}) and a heart rate of 118 beats/min118\text{ beats/min}. Which of the following actions should the nurse take? (Select all that apply.)

  1. Stop the blood transfusion immediately.Answer
  2. Replace the blood administration set with new tubing primed with 0.9%0.9\% sodium chloride.Answer
  3. Obtain a urine specimen from the client to send to the laboratory.Answer
  4. D
    Administer prescribed intravenous diphenhydramine through the existing blood administration tubing.
  5. E
    Delegate the continuous monitoring of the client's vital signs to the unlicensed assistive personnel.
  6. F
    Decrease the rate of the transfusion and administer prescribed as-needed acetaminophen.

Answer

The nurse should stop the blood transfusion immediately, replace the blood administration set with new tubing primed with 0.9% sodium chloride, and obtain a urine specimen from the client.
The client is exhibiting signs of an acute hemolytic transfusion reaction. The correct sequence of priority actions involves stopping the offending agent immediately, maintaining venous access with new tubing and compatible normal saline to support blood pressure and renal perfusion, and collecting a urine specimen to assess for hemoglobinuria caused by the breakdown of red blood cells.

Step-by-Step Solution

1
Analyze the client's symptoms.
The client has lower back pain, fever, chills, tachycardia, and dyspnea shortly after starting a transfusion.
These are the classic hallmark signs of an acute hemolytic transfusion reaction, a life-threatening emergency.
2
Determine the most critical immediate intervention.
The transfusion must be stopped immediately.
Halting the infusion prevents any additional incompatible red blood cells from entering the client's bloodstream.
3
Determine how to safely maintain intravenous access.
The nurse must attach completely new IV tubing primed with 0.9% sodium chloride.
Flushing the existing blood tubing would dangerously push the remaining incompatible blood into the client. Normal saline is the only compatible fluid.
4
Identify required diagnostic follow-up.
A urine specimen must be collected.
A urine sample is needed to check for hemoglobinuria, which confirms the destruction of red blood cells (hemolysis) in the kidneys.

Key Concept

Management of Acute Hemolytic Transfusion Reactions
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Topics

Pharmacological and Parenteral Therapies

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