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Difficulty: Very hardPharmacological and Parenteral Therapies

While a unit of packed red blood cells (PRBCs) is infusing, the client suddenly develops severe lower back pain, dyspnea, and visible shivering. The nurse suspects an acute hemolytic transfusion reaction. Arrange the following nursing interventions in the correct chronological order of priority. (Place the first action at the top and the last action at the bottom.)

  1. 1Stop the blood transfusion immediately.
  2. 2Disconnect the blood administration set from the client's intravenous hub.
  3. 3Attach a new intravenous tubing primed with 0.9% sodium chloride and maintain the line.
  4. 4Assess the client's vital signs and respiratory status.
  5. 5Notify the primary healthcare provider and the blood bank.
  6. 6Send the discontinued blood bag and administration set to the blood bank.

Answer

The correct sequence is to first stop the transfusion, then disconnect the blood tubing, attach new tubing primed with 0.9% sodium chloride, assess the client's status, notify the provider and blood bank, and finally send the equipment to the blood bank for testing.
The correct sequence prioritizes immediate patient safety by stopping the administration of the offending agent, physically disconnecting it, and securing venous access with a new line. Only after these lifesaving actions are complete should the nurse gather assessment data to communicate with the medical team, and finally preserve the evidence for laboratory investigation.

Step-by-Step Solution

1
Stop the blood transfusion.
The infusion of the potentially incompatible blood product is halted.
This is the most critical first step to prevent further physiological harm to a client experiencing an acute hemolytic reaction.
2
Disconnect the blood administration set from the intravenous hub.
The source of the incompatible blood is physically separated from the client's vascular access.
This prevents inadvertently pushing the remaining blood in the tubing into the client during the subsequent flush.
3
Attach a new intravenous tubing primed with 0.9% sodium chloride.
A patent intravenous line is secured with a compatible isotonic fluid.
Intravenous access must be maintained for potential emergency interventions, fluid resuscitation, and blood pressure support.
4
Assess the client's vital signs and clinical status.
Objective data regarding the severity of the reaction is gathered.
The nurse must evaluate the client's respiratory, hemodynamic, and neurological status to provide accurate and current information to the healthcare provider.
5
Notify the primary healthcare provider and the blood bank.
The medical team is alerted, and further emergency orders can be obtained.
The provider needs the assessment data to prescribe interventions (e.g., epinephrine, vasopressors, antihistamines), and the blood bank must initiate a reaction investigation.
6
Send the discontinued blood bag and administration set to the blood bank.
The suspected blood product is transported for laboratory analysis.
Testing the remaining blood and tubing is required to confirm the type of reaction, such as an ABO incompatibility.

Key Concept

Management of Acute Hemolytic Transfusion Reaction
Estimated Time:2m 0s
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Topics

Pharmacological and Parenteral Therapies

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