A client on a medical-surgical unit is receiving an infusion of packed red blood cells (PRBCs) for symptomatic anemia. Ten minutes after the transfusion begins, the client reports sudden severe lower back pain, dyspnea, and chills. The nurse notes visible flushing and shivering. Place the following nursing interventions in the correct order of priority. (Arrange from first action to last action.)
- 1Stop the blood transfusion immediately.
- 2Change the IV tubing and infuse 0.9% sodium chloride.
- 3Assess the client's vital signs and clinical status.
- 4Notify the primary healthcare provider and the blood bank.
- 5Return the blood bag, attached tubing, and labels to the blood bank.
Answer
The correct sequence of actions for a suspected blood transfusion reaction is: 1) Stop the blood transfusion immediately. 2) Change the IV tubing and infuse 0.9% sodium chloride. 3) Assess the client's vital signs and clinical status. 4) Notify the primary healthcare provider and the blood bank. 5) Return the blood bag, attached tubing, and labels to the blood bank.
In any adverse transfusion reaction, the absolute first priority is to remove the source of harm (stop the transfusion). The second priority is to maintain an open venous access line for emergency medications using entirely new tubing and normal saline. Assessing the client follows securing the line, providing the necessary clinical data to report to the healthcare provider. The provider is then notified, and finally, administrative and diagnostic protocols such as returning the blood to the lab are completed.
Step-by-Step Solution
Key Concept
Management of acute hemolytic transfusion reactions requires immediate cessation of the blood product, maintaining a patent IV with new tubing, and comprehensive client assessment before provider notification.