A nurse is caring for a client receiving a packed red blood cell (PRBC) transfusion. Fifteen minutes into the transfusion, the client reports sudden chills, severe lower back pain, and shortness of breath. In what chronological order should the nurse perform the following actions to reduce the risk of further physiological deterioration? Arrange the actions from first to last.
- 1Stop the blood transfusion immediately.
- 2Replace the IV tubing and initiate an infusion of 0.9% sodium chloride.
- 3Assess the client's vital signs and respiratory status.
- 4Notify the primary healthcare provider and the blood bank.
- 5Return the blood bag, attached tubing, and transfusion record to the blood bank.
Answer
The correct sequence is: Stop the transfusion, replace the IV tubing with normal saline, assess the client, notify the provider and blood bank, and finally return the blood products to the blood bank.
In any severe adverse reaction, the immediate priority is to stop the offending agent. Following cessation, maintaining vascular access with new tubing and normal saline ensures the client can receive emergency treatments without receiving more blood. Only after stabilizing the line should the nurse assess the client fully to gather data for the provider. Notification follows assessment, and administrative tasks (returning the bag for investigation) are completed last.
Step-by-Step Solution
Key Concept
Management of acute hemolytic transfusion reactions prioritizes immediately stopping the causative agent, maintaining hemodynamic stability, and communicating findings.