A nurse is caring for a client who is receiving a packed red blood cell (PRBC) transfusion. Fifteen minutes after the transfusion begins, the client reports sudden lower back pain, chills, and shortness of breath. In which order should the nurse perform the following actions? Arrange the actions from first to last.
- 1Stop the blood transfusion immediately.
- 2Disconnect the blood tubing and initiate an infusion of 0.9% sodium chloride using new tubing.
- 3Assess the client's vital signs and respiratory status.
- 4Notify the healthcare provider and the facility blood bank.
- 5Return the blood bag and administration set to the blood bank.
Answer
Stop the transfusion, initiate normal saline with new tubing, assess the client, notify the provider and blood bank, and return the blood product to the blood bank.
The absolute priority when a transfusion reaction is suspected is to prevent further exposure to the blood product, maintain venous access, assess the client, and obtain medical intervention. Stopping the transfusion immediately is always the first step, followed by maintaining the intravenous line with 0.9% sodium chloride through entirely new tubing to prevent infusing residual blood. Next, assessing the client provides critical baseline data for the healthcare provider. Notifying the provider and blood bank allows for rapid emergency interventions. Finally, returning the blood bag and tubing allows the facility to analyze the cause of the reaction.
Step-by-Step Solution
Key Concept
Management of a suspected hemolytic blood transfusion reaction.
Estimated Time:1m 0s