A nurse is caring for a client who is receiving an infusion of packed red blood cells (PRBCs). 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.
- 2Infuse 0.9% sodium chloride through a new intravenous tubing set.
- 3Assess the client's vital signs and respiratory status.
- 4Notify the healthcare provider of the client's condition.
- 5Send the blood bag and administration set to the blood bank.
Answer
The correct sequence is: Stop the transfusion, infuse 0.9% sodium chloride with new tubing, assess vital signs, notify the healthcare provider, and send the blood bag to the blood bank.
When a hemolytic transfusion reaction occurs, characterized by lower back pain, chills, and dyspnea, the absolute first step is to stop the transfusion to prevent further physiological harm. Next, the nurse must maintain a patent IV line with 0.9% sodium chloride using completely new tubing so that residual blood is not pushed into the client. The nurse then quickly assesses vital signs to gather current physiological data. With this information, the nurse notifies the healthcare provider using the SBAR framework to obtain emergency orders. Finally, once the immediate threat is managed, the blood bag and tubing are sent to the blood bank for analysis.
Step-by-Step Solution
Key Concept
Management of acute hemolytic transfusion reactions
Estimated Time:1m 30s