A nurse is monitoring a client who is receiving a transfusion of packed red blood cells (PRBCs). Fifteen minutes into the transfusion, the client reports sudden 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 normal saline with new IV tubing.
- 3Assess the client's vital signs and respiratory status.
- 4Notify the healthcare provider and the blood bank.
Answer
1. Stop the blood transfusion immediately. 2. Disconnect the blood tubing and initiate normal saline with new IV tubing. 3. Assess the client's vital signs and respiratory status. 4. Notify the healthcare provider and the blood bank.
The priority in any acute hemolytic transfusion reaction is to immediately stop the infusion of the incompatible blood product to minimize physiological harm. After stopping the transfusion, the nurse must maintain a patent intravenous line using normal saline and completely new tubing to ensure emergency medications can be given without pushing residual blood into the client. Once the source is removed and access is secured, the nurse performs a rapid assessment of vital signs and respiratory status to determine the severity of the reaction. Finally, the nurse notifies the healthcare provider to obtain treatment prescriptions and the blood bank to initiate a formal transfusion reaction investigation.
Step-by-Step Solution
Key Concept
Prioritization in Acute Transfusion Reactions