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Difficulty: MediumReduction of Risk Potential

A nurse is monitoring an adult client who is receiving a unit of packed red blood cells (PRBCs). Fifteen minutes into the infusion, the client suddenly reports severe lower back pain, chills, and shortness of breath. To reduce the risk of severe physiological complications, arrange the following nursing actions in the correct priority sequence. (Arrange the first action at the top and the final action at the bottom).

  1. 1Stop the blood transfusion immediately.
  2. 2Disconnect the blood tubing and initiate normal saline using new intravenous tubing.
  3. 3Assess the client's vital signs and respiratory status.
  4. 4Notify the healthcare provider and the blood bank of the suspected reaction.
  5. 5Return the blood bag, attached administration set, and labels to the blood bank.

Answer

The correct sequence is: 1) Stop the blood transfusion immediately, 2) Disconnect the blood tubing and initiate normal saline using new intravenous tubing, 3) Assess the client's vital signs and respiratory status, 4) Notify the healthcare provider and the blood bank of the suspected reaction, 5) Return the blood bag, attached administration set, and labels to the blood bank.
In the event of a suspected severe transfusion reaction, the priority is to stop the source of the injury. Therefore, stopping the transfusion is the absolute first action. Secondly, intravenous access must be maintained for emergency resuscitation, requiring normal saline to be infused through entirely new tubing to prevent flushing remaining blood into the client. Thirdly, a rapid physiological assessment of vital signs provides necessary data about the severity of the reaction (e.g., hypotension, hypoxia). Fourth, the healthcare provider and blood bank are notified, utilizing the gathered assessment data to receive medical orders. Finally, returning the blood bag and tubing to the blood bank is completed for diagnostic analysis after the client is stabilized.

Step-by-Step Solution

1
Identify the clinical signs of a severe transfusion reaction.
The client's lower back pain, chills, and shortness of breath indicate a potential acute hemolytic transfusion reaction.
Early recognition of a transfusion reaction dictates immediate emergency intervention to prevent morbidity or mortality.
2
Determine the first priority to reduce further risk to the client.
Stopping the transfusion immediately is prioritized above all other actions.
Halting the infusion prevents any additional incompatible red blood cells from entering the client's circulation, thereby limiting the severity of the reaction.
3
Establish the next immediate physical intervention to preserve safety.
Maintaining a patent intravenous line with normal saline using new tubing is the second step.
A patent line is critical for administering emergency fluids or medications. Flushing with the existing blood tubing would incorrectly push more incompatible blood into the client.
4
Prioritize the remaining assessment, communication, and procedural tasks.
Assessment of vital signs precedes notifying the provider, followed by returning the equipment to the blood bank.
The provider needs current vital signs to prescribe appropriate emergency orders. Returning the blood bag is a necessary administrative and diagnostic step but has the lowest immediate physiological priority.

Key Concept

Management of Acute Hemolytic Transfusion Reactions
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Topics

Reduction of Risk Potential

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