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Difficulty: EasyPhysiological Adaptation

A nurse is caring for a client who is receiving a packed red blood cell (PRBC) transfusion. The client suddenly develops severe chills, lower back pain, and dyspnea. Arrange the following nursing actions in the correct order of priority from first to perform to last.

  1. 1Stop the blood transfusion immediately.
  2. 2Maintain the intravenous (IV) line with a new tubing setup of 0.9% sodium chloride.
  3. 3Assess the client's vital signs and respiratory status.
  4. 4Notify the healthcare provider and the blood bank.

Answer

The correct sequence is: first, stop the blood transfusion immediately; second, maintain the IV line with new tubing and 0.9% sodium chloride; third, assess the client's vital signs; and fourth, notify the healthcare provider and blood bank.
In any acute allergic or hemolytic reaction to an intravenous therapy, the absolute priority is to stop the offending agent immediately. Following this, the nurse must maintain IV access with normal saline using new tubing so that emergency medications can be administered safely. Only after securing the line and halting the harm should the nurse perform a full assessment to gather data, which is then relayed to the healthcare provider to obtain further medical orders.

Step-by-Step Solution

1
Identify the primary threat and stop the offending agent.
The blood transfusion is stopped immediately.
Chills, lower back pain, and dyspnea are classic signs of an acute hemolytic transfusion reaction. Stopping the blood prevents further physiological harm.
2
Secure intravenous access for emergency interventions.
A normal saline infusion is started using completely new IV tubing.
The client may require emergency medications or fluid resuscitation to maintain blood pressure and urine output. New tubing ensures no residual blood is flushed into the client.
3
Gather clinical data regarding the client's status.
Vital signs and respiratory status are assessed.
The severity of the reaction must be evaluated to provide the healthcare provider with an accurate clinical picture.
4
Escalate the situation to the appropriate interdisciplinary team members.
The healthcare provider and blood bank are notified.
The provider needs to prescribe emergency medical interventions, and the blood bank must initiate a transfusion reaction investigation.

Key Concept

Prioritization of Interventions in Acute Transfusion Reactions
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Topics

Physiological Adaptation

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