A nurse is monitoring a client who is receiving an intravenous infusion of packed red blood cells (PRBCs). Fifteen minutes after the transfusion begins, the client becomes restless, reports severe lower back pain, and the nurse notes the client's temperature has increased by 1.5°C (2.7°F). Arrange the following nursing actions in the correct priority order from first to last.
- 1Stop the blood transfusion immediately.
- 2Disconnect the blood tubing and initiate 0.9% sodium chloride with new tubing.
- 3Assess the client's vital signs and respiratory status.
- 4Notify the healthcare provider and the blood bank.
- 5Return the blood bag, tubing, and labels to the blood bank.
Answer
The correct sequence of actions is to first stop the transfusion, then maintain IV access with new tubing and normal saline, assess vital signs, notify the provider and blood bank, and finally return the blood products to the blood bank.
In any acute medical emergency, the nurse's first action is to remove or stop the causative agent. For a transfusion reaction, stopping the blood immediately is the absolute priority. Maintaining IV access with new tubing and saline ensures a route for emergency drugs without pushing more blood into the client. Assessing the client provides the necessary data to communicate effectively with the healthcare provider. Notifying the provider allows for emergency orders, and returning the blood products allows the blood bank to thoroughly investigate the reaction.
Step-by-Step Solution
Key Concept
Prioritization of care during an acute hemolytic blood transfusion reaction
Estimated Time:1m 30s