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Soru

Zorluk: ZorReduction of Risk Potential

A client receiving an intravenous transfusion of packed red blood cells (PRBCs) suddenly reports severe lower back pain, chills, and shortness of breath. To reduce the risk of severe physiological complications from a suspected acute hemolytic transfusion reaction, arrange the following nursing actions in the correct priority sequence.

  1. 1Stop the transfusion of packed red blood cells immediately.
  2. 2Disconnect the blood administration set and initiate an infusion of normal saline using new intravenous tubing.
  3. 3Assess the client's vital signs, respiratory status, and overall clinical condition.
  4. 4Notify the healthcare provider and the hospital blood bank of the suspected adverse reaction.
  5. 5Collect required client blood and urine samples and send them along with the discontinued blood product to the laboratory.

Cevap

The correct sequence is to first stop the transfusion, second disconnect the tubing and initiate normal saline with new tubing, third assess the client's vital signs and clinical status, fourth notify the healthcare provider and blood bank, and fifth collect required specimens and send the blood product to the laboratory.
The priority in any acute hemolytic transfusion reaction is to immediately stop the exposure to the incompatible antigen. Following this, maintaining a patent IV with normal saline via new tubing ensures emergency access without infusing the residual blood in the old tubing. Only after the client is protected from further harm and IV access is secured should the nurse perform a full assessment, notify the provider with the assessment findings, and finally handle the collection of laboratory specimens.

Adım Adım Çözüm

1
Identify the signs of an acute hemolytic transfusion reaction.
The nurse recognizes lower back pain, chills, and shortness of breath as medical emergencies requiring immediate intervention.
Early recognition is crucial for initiating risk reduction measures and preventing severe renal or cardiopulmonary failure.
2
Prioritize immediate physical risk reduction interventions.
The nurse stops the transfusion and secures IV access with a normal saline infusion via new tubing.
Stopping the infusion prevents further antigen exposure, and a new saline line ensures patent access for emergency medications without flushing residual blood into the client.
3
Gather clinical data and escalate care to the interdisciplinary team.
The nurse assesses vital signs, notifies the provider and blood bank, and sends required specimens to the laboratory.
Assessment data guides the provider's emergency prescriptions, while laboratory analysis of the blood and urine confirms hemolysis and dictates further systemic treatments.

Anahtar Kavram

Nursing management of an acute hemolytic transfusion reaction to reduce the risk of systemic complications.

Alternatif Yöntem

While the physical steps follow a strict chronological protocol, cognitive delegation can occur simultaneously. If a second nurse or rapid response team member is present, the primary nurse can delegate notifying the provider and blood bank while continuing to independently manage the airway and IV access.
Tahmini Süre:1m 30s
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Reduction of Risk Potential

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