A practical nurse (PN) is monitoring a client who is receiving a packed red blood cell (PRBC) transfusion. The client suddenly reports severe lower back pain and begins to experience chills. In what order should the PN perform the following actions? Arrange the actions in the correct sequence from first to last.
- 1Stop the blood transfusion immediately.
- 2Maintain the intravenous (IV) line open with normal saline.
- 3Notify the supervising registered nurse (RN).
- 4Obtain the client's vital signs.
Cevap
The correct sequence is to first stop the blood transfusion, then maintain the IV line with normal saline, notify the supervising RN, and finally obtain the client's vital signs.
In any suspected blood transfusion reaction, the absolute highest priority is to stop the source of the reaction to prevent further harm. After stopping the blood, the IV site must be maintained with a normal saline infusion using new tubing to keep the vein open for emergency interventions. The RN must then be notified immediately to further assess the client and contact the healthcare provider. Finally, the PN obtains vital signs to establish the client's current status and monitor for impending shock.
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Anahtar Kavram
Prioritization during a suspected blood transfusion reaction