A nurse is monitoring a client who is receiving a transfusion of packed red blood cells. Ten minutes after the transfusion begins, the client reports sudden chills, severe lower back pain, and shortness of breath. Arrange the following nursing actions in the correct priority order to manage this situation from first to last.
- 1Stop the blood transfusion immediately.
- 2Disconnect the blood tubing and connect a new normal saline infusion to the intravenous site.
- 3Assess the client's vital signs and respiratory status.
- 4Notify the healthcare provider and the blood bank.
- 5Return the remaining blood product and tubing to the blood bank.
Answer
The correct sequence is to first stop the transfusion to prevent further exposure, then maintain IV access with new tubing and normal saline, followed by a rapid assessment of the client. After mitigating immediate threats, the nurse notifies the provider and blood bank, and finally returns the equipment for diagnostic investigation.
In a suspected acute hemolytic transfusion reaction, the most critical risk reduction action is to remove the offending agent by stopping the transfusion immediately. Next, patent IV access must be maintained with completely new tubing and normal saline to prevent flushing residual blood into the client and to allow for emergency medication administration. Only after securing safety and access should the nurse assess the client's current status to report accurate findings to the provider. Finally, the remaining blood products are sent to the blood bank for mandatory analysis.
Step-by-Step Solution
Key Concept
Management of Acute Hemolytic Transfusion Reactions