A nurse is caring for a client who is receiving a transfusion of packed red blood cells. Fifteen minutes after the transfusion begins, the client suddenly reports severe lower back pain, chills, and dyspnea. Place the following nursing interventions in the correct order of priority from first to last.
- 1Stop the blood transfusion immediately.
- 2Disconnect the blood tubing and initiate an infusion of 0.9% sodium chloride using new tubing.
- 3Assess the client's vital signs and respiratory status.
- 4Notify the healthcare provider and the blood bank.
- 5Send the blood bag, attached tubing, and labels to the blood bank for analysis.
Answer
The correct sequence is to first stop the transfusion, then maintain intravenous access with normal saline using new tubing, assess the client's vital signs, notify the healthcare provider, and finally send the blood products back to the blood bank.
In an acute hemolytic or allergic transfusion reaction, the priority follows a strict physiological adaptation protocol. The absolute highest priority is stopping the source of harm (the blood). The second priority is maintaining vascular access with new tubing to avoid flushing more blood into the client. Once the line is secure, the nurse assesses the client to determine the extent of the physiological compromise. This assessment data is then communicated to the healthcare provider to obtain emergency prescriptions. Returning the blood bag for diagnostic analysis is an administrative task that occurs last.
Step-by-Step Solution
Key Concept
Management of Acute Blood Transfusion Reactions