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Difficulty: MediumPhysiological Adaptation

A nurse is monitoring a client receiving a transfusion of packed red blood cells. Fifteen minutes after the infusion begins, the client suddenly develops severe lower back pain, chills, and dyspnea. Suspecting an acute hemolytic transfusion reaction, arrange the following nursing actions in the correct priority sequence from first to last.

  1. 1Stop the blood transfusion immediately.
  2. 2Replace the blood tubing with a new set primed with 0.9% sodium chloride.
  3. 3Assess the client's vital signs and cardiopulmonary status.
  4. 4Notify the healthcare provider and the blood bank.
  5. 5Return the blood bag, tubing, and required client samples to the laboratory.

Answer

The correct sequence is to first stop the transfusion, then replace the tubing to infuse normal saline, assess the client, notify the provider and blood bank, and finally send the materials to the lab.
In any acute medical emergency caused by an external agent, the first priority is to remove or stop the causative agent. Therefore, stopping the transfusion is step one. Maintaining IV access with normal saline using new tubing is step two, ensuring a lifeline is available without worsening the reaction. Step three is assessing the client to determine the exact physiological impact. Step four is notifying the provider using the gathered assessment data. Step five, the final administrative and diagnostic step, is sending the materials to the lab.

Step-by-Step Solution

1
Identify the primary source of harm and intervene immediately.
The blood transfusion is stopped.
Continuing the transfusion, even for a few more seconds, exacerbates the acute hemolytic reaction.
2
Maintain vascular access without administering more of the offending agent.
New IV tubing is attached and normal saline is infused.
Using the existing blood tubing would push the remaining blood into the client. Normal saline maintains line patency for emergency drugs.
3
Determine the client's physiological baseline following the insult.
Vital signs and respiratory status are assessed.
Objective data is required to communicate the client's status to the provider and anticipate necessary interventions (e.g., oxygen, epinephrine, diuretics).
4
Communicate the crisis to the interdisciplinary team.
The healthcare provider and blood bank are notified.
The provider must prescribe medical interventions, and the blood bank must initiate their internal investigation protocols.
5
Facilitate diagnostic investigation.
Blood bag, tubing, and client samples are sent to the laboratory.
This confirms the type of reaction and determines if a systemic error occurred, but it is the lowest priority compared to client stabilization.

Key Concept

Priority Management of Suspected Transfusion Reactions
Estimated Time:1m 30s
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Topics

Physiological Adaptation

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