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Difficulty: MediumPharmacological and Parenteral Therapies

A nurse is monitoring a client who is receiving an intravenous (IV) transfusion of packed red blood cells (PRBCs). Fifteen minutes after the transfusion begins, the client reports sudden lower back pain and chills. The client's heart rate increases from 82 to 118 beats/min, and blood pressure drops from 124/76 mm Hg to 92/58 mm Hg. Which of the following is the priority nursing action?

  1. Stop the transfusion and initiate a 0.9% sodium chloride infusion using new IV tubing.Answer
  2. B
    Slow the transfusion rate and immediately notify the healthcare provider of the vital sign changes.
  3. C
    Administer the prescribed PRN dose of intravenous acetaminophen to treat the client's chills and prevent fever.
  4. D
    Disconnect the blood bag and flush the existing IV tubing with 0.9% sodium chloride to maintain access.

Answer

Stop the transfusion and initiate a 0.9% sodium chloride infusion using new IV tubing.
The client's presentation of sudden lower back pain, chills, tachycardia, and hypotension shortly after starting a blood transfusion strongly indicates an acute hemolytic reaction. The absolute priority is to stop the transfusion immediately to prevent further infusion of incompatible cells. Maintaining venous access is critical for subsequent emergency treatment and volume resuscitation, but it must be done using completely new tubing and 0.9% sodium chloride to avoid pushing any remaining blood from the old tubing into the client.

Step-by-Step Solution

1
Identify the clinical signs presented by the client.
The client is experiencing sudden lower back pain, chills, tachycardia, and hypotension shortly after a blood transfusion was initiated.
These are classic, life-threatening signs of an acute hemolytic transfusion reaction.
2
Determine the immediate nursing priority based on the assessment.
The source of the reaction (the blood product) must be halted immediately to prevent further systemic harm.
Patient safety principles and airway, breathing, circulation (ABC) prioritization require stopping the administration of the offending antigen before any other intervention.
3
Select the appropriate technical intervention to secure the client's safety.
Stop the blood and hang 0.9% sodium chloride with completely new tubing.
This maintains critical IV access for emergency medications without infusing any remaining red blood cells from the old tubing into the client.

Key Concept

Acute Hemolytic Transfusion Reaction Management
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Topics

Pharmacological and Parenteral Therapies

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