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Question 3881Question →

A nurse is caring for a client who is receiving a unit of packed red blood cells (PRBCs). Fifteen minutes after the transfusion begins, the client reports severe lower back pain, chills, and shortness of breath. Arrange the following nursing actions in the priority order they should be performed.

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Answer

The correct sequence is to first stop the transfusion, then replace the IV tubing to infuse normal saline, assess the client's vital signs, notify the healthcare provider and blood bank, and finally return the blood product to the lab.
In a suspected transfusion reaction, the priority sequence follows the principle of halting the trigger, maintaining physiological support, assessing the damage, and then communicating findings. Stopping the blood is always the first action. Maintaining IV access with new tubing prevents infusing residual blood while keeping a line open for emergency drugs. Assessing the client provides the necessary clinical picture before notifying the provider. Finally, returning the materials allows the laboratory to investigate the cause.

Step-by-Step Solution

1
Stop the transfusion immediately.
Prevents further administration of incompatible blood.
Halting the offending agent is the primary physiological adaptation intervention in any hypersensitivity or hemolytic reaction.
2
Replace the IV tubing and infuse 0.9% sodium chloride.
Maintains IV access without pushing more blood into the client.
IV access is critical for resuscitation. Using the existing tubing would inappropriately flush incompatible red blood cells into the client's circulation.
3
Assess the client's vital signs and respiratory status.
Provides current physiological baseline data.
Accurate clinical data is necessary to guide medical treatment and properly inform the healthcare provider of the client's status.
4
Notify the healthcare provider and the blood bank.
Initiates collaborative medical management.
The provider will prescribe emergency medications (e.g., epinephrine, diuretics, fluids), and the blood bank must begin an investigation into the reaction.
5
Return the blood bag, tags, and tubing to the blood bank.
Allows for laboratory analysis of the reaction.
This is standard post-reaction protocol to determine the exact cause of the hemolytic or allergic event.

Key Concept

Acute Hemolytic Transfusion Reaction Management
Estimated Time:1m 30s
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