A nurse is caring for a client who is receiving an intravenous transfusion of packed red blood cells (PRBCs). Fifteen minutes after the infusion begins, the client becomes restless and reports sudden chills and severe lower back pain. In what order should the nurse perform the following interventions? Arrange the actions from first to last.
- 1Stop the blood transfusion immediately.
- 2Maintain the intravenous line with normal saline using new tubing.
- 3Assess the client's vital signs and respiratory status.
- 4Notify the healthcare provider and the blood bank.
- 5Return the blood bag and attached administration set to the blood bank.
Answer
The correct sequence of actions is: stop the transfusion immediately, maintain the IV line with normal saline using completely new tubing, assess the client's vital signs, notify the healthcare provider and blood bank, and finally return the blood bag and tubing to the blood bank.
Acute hemolytic transfusion reactions present rapidly with chills, lower back pain, tachycardia, and hypotension. According to prioritization principles, the absolute priority is to stop the infusion to prevent further exposure to the incompatible antigen. Next, the nurse must ensure a patent IV line using a completely new tubing setup with normal saline to avoid flushing any residual blood into the client. Once the source of harm is stopped and vascular access is secured, the nurse performs a focused assessment to gather vital data. This assessment data is then communicated to the healthcare provider and the blood bank. Finally, the remaining blood product and all associated tubing are sent to the laboratory for required crossmatch and contamination testing.
Step-by-Step Solution
Key Concept
Management of a suspected acute hemolytic transfusion reaction