A nurse is caring for a client who is receiving a packed red blood cell (PRBC) transfusion. Fifteen minutes after the transfusion begins, the client reports severe lower back pain, shortness of breath, and chills. Arrange the following nursing actions in the correct priority order from first to last.
- 1Stop the blood transfusion immediately.
- 2Disconnect the blood tubing and attach new tubing infused with 0.9% sodium chloride.
- 3Assess the client's vital signs and respiratory status.
- 4Notify the healthcare provider and the blood bank of the suspected reaction.
- 5Send the remaining blood product and original tubing to the blood bank for analysis.
Answer
The correct sequence is to first stop the transfusion, then maintain IV access with normal saline using new tubing, followed by assessing the client, notifying the provider and blood bank, and finally sending the blood bag and tubing back to the blood bank.
According to prioritization principles, when a client experiences an adverse reaction to an infusion, the immediate priority is to stop the causative agent. Next, the nurse must maintain a patent IV line with normal saline using new tubing to ensure emergency medications can be given without flushing more of the reactive blood into the client. Only after these immediate safety measures are taken should the nurse conduct a full assessment, notify the provider, and handle the blood products.
Step-by-Step Solution
Key Concept
Management of Acute Hemolytic Transfusion Reactions
Estimated Time:1m 30s