Thirty minutes after initiating a transfusion of packed red blood cells (PRBCs), the nurse observes the client exhibiting sudden dyspnea, tachypnea, and severe flank pain. The client states, "I feel freezing cold." Arrange the following nursing interventions in the prioritized order they should be performed, from first to last.
- 1Stop the blood transfusion completely.
- 2Disconnect the blood tubing and infuse 0.9% sodium chloride through a new intravenous administration set.
- 3Obtain the client's current vital signs and auscultate lung sounds.
- 4Notify the healthcare provider and the institutional blood bank.
- 5Return the discontinued blood bag and administration set to the blood bank.
Cevap
The correct sequence of interventions is: 1) Stop the blood transfusion completely, 2) Disconnect the blood tubing and infuse 0.9% sodium chloride through a new intravenous administration set, 3) Obtain the client's current vital signs and auscultate lung sounds, 4) Notify the healthcare provider and the institutional blood bank, 5) Return the discontinued blood bag and administration set to the blood bank.
In any acute emergency involving an infusing substance, the absolute highest priority is to stop the offending agent immediately to prevent further harm. Following acute survival priorities, the nurse must stop the blood first. Second, the nurse must secure a patent IV line with new tubing to avoid flushing remaining blood into the client. Third, the nurse assesses the client to gather critical data. Fourth, the provider is notified for medical orders using the gathered data. Finally, the nurse follows institutional protocol by sending the equipment for diagnostic analysis.
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Prioritization of interventions during an acute blood transfusion reaction.
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