A nurse is caring for a client who is receiving a transfusion of packed red blood cells (PRBCs). Fifteen minutes into the transfusion, the client reports severe lower back pain, chills, and shortness of breath. Arrange the following nursing actions 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.
- 3Obtain the client's vital signs and perform a focused respiratory assessment.
- 4Notify the healthcare provider and the facility's blood bank.
- 5Return the blood bag and attached administration set to the blood bank.
Answer
The correct sequence is: Stop the transfusion, maintain the IV with normal saline using new tubing, assess the client's vital signs, notify the provider and blood bank, and return the blood materials to the blood bank.
In a suspected hemolytic blood transfusion reaction, the absolute first clinical priority is to stop the transfusion to prevent further exposure to incompatible blood. Next, the nurse must maintain intravenous access with 0.9% sodium chloride through new tubing to keep the vein open for emergency drugs without infusing the remaining blood in the old tubing. After stabilizing the IV line, the nurse assesses the client's vital signs and respiratory status to gather essential data. This data is then reported when notifying the healthcare provider and blood bank. Finally, the blood bag and tubing are returned to the blood bank for further investigation.
Step-by-Step Solution
Key Concept
Management of Acute Hemolytic Transfusion Reaction
Estimated Time:1m 30s