An adult client on a medical-surgical unit is receiving a continuous intravenous infusion of packed red blood cells (PRBCs). Twenty minutes into the transfusion, the client reports sudden severe lower back pain, chills, and shortness of breath. Arrange the following nursing actions in the priority order they should be implemented, from first to last.
- 1Stop the blood transfusion immediately.
- 2Disconnect the blood tubing at the catheter hub and initiate a normal saline infusion with new tubing.
- 3Assess the client's vital signs and respiratory status.
- 4Notify the primary healthcare provider and the blood bank of the reaction.
- 5Return the remaining blood bag and administration set to the blood bank for testing.
Answer
The correct sequence of actions for a suspected hemolytic transfusion reaction is to first stop the transfusion, followed by maintaining IV access with normal saline using new tubing, assessing the client's physiological status, notifying the provider and blood bank, and finally returning the blood products for testing.
In any acute deterioration or adverse reaction, the immediate priority is to stop the offending agent (the blood product) to prevent further harm. The next immediate priority is physiological stabilization, which involves maintaining a patent IV with new tubing for emergency medications. Once immediate physical safety is secured, the nurse must assess the client's current status to provide accurate data when notifying the provider. Finally, administrative and diagnostic tasks, such as returning the blood product to the lab, are completed.
Step-by-Step Solution
Key Concept
Prioritization of nursing interventions during an acute hemolytic transfusion reaction
Estimated Time:1m 30s