Examkin

Soru

Zorluk: OrtaReduction of Risk Potential

A practical nurse is monitoring a client who is receiving a packed red blood cell (PRBC) transfusion. Fifteen minutes into the infusion, the client suddenly reports severe lower back pain and chills. In what order should the practical nurse perform the following actions? Arrange the steps from first to last.

  1. 1Stop the blood transfusion immediately.
  2. 2Disconnect the blood tubing and initiate 0.9% sodium chloride using new IV tubing.
  3. 3Obtain a complete set of the client's vital signs.
  4. 4Notify the registered nurse and the prescribing healthcare provider.
  5. 5Send the remaining blood, bag, and attached tubing to the blood bank.

Cevap

The correct sequence is: Stop the blood transfusion, initiate 0.9% sodium chloride with new tubing, obtain vital signs, notify the registered nurse and healthcare provider, and finally send the remaining blood and tubing to the blood bank.
When a client exhibits signs of a severe transfusion reaction, such as lower back pain and chills, the absolute first priority is to stop the infusion. Once the source of harm is stopped, the nurse must maintain IV access using normal saline and new tubing to prepare for emergency medication administration. After securing the line, the nurse obtains vital signs to report a complete clinical picture to the RN and healthcare provider. Finally, the blood and tubing are sent to the blood bank per facility protocol for diagnostic analysis.

Adım Adım Çözüm

1
Identify the immediate life threat and intervene.
The transfusion is stopped immediately.
Lower back pain and chills are classic signs of a hemolytic transfusion reaction. The source of the reaction must be halted immediately to minimize harm.
2
Maintain vascular access without worsening the reaction.
0.9% sodium chloride is infused through completely new tubing.
If the existing tubing is flushed, the remaining blood in the line will be pushed into the client. New tubing ensures only normal saline enters the vein, keeping the line open for emergency drugs.
3
Assess the client's physiological status.
A full set of vital signs is obtained.
The nurse needs current baseline data (blood pressure, heart rate, temperature, oxygen saturation) to understand the physiological impact of the reaction.
4
Escalate the situation to higher-level providers.
The RN and healthcare provider are notified.
The provider needs the assessment data to order appropriate interventions, such as antihistamines, corticosteroids, or vasopressors.
5
Preserve evidence for institutional analysis.
The blood bag and tubing are sent to the blood bank.
The blood bank must analyze the remaining product to identify cross-matching errors or bacterial contamination.

Anahtar Kavram

Reduction of Risk Potential: Emergency Management of Transfusion Reactions
Bu soruyu puanla

Konular

Reduction of Risk Potential

Bu konudan daha fazla soru