A nurse is caring for a client who is receiving a transfusion of packed red blood cells. The client suddenly reports severe lower back pain and chills. Arrange the following nursing actions in the correct order of priority to minimize physiological risk to the client.
- 1Stop the blood transfusion immediately.
- 2Disconnect the blood tubing and infuse normal saline through new tubing.
- 3Assess the client's vital signs, breath sounds, and urine output.
- 4Notify the healthcare provider of the client's status.
- 5Send the blood bag, attached tubing, and client specimens to the laboratory.
Cevap
The correct sequence is to first stop the transfusion, then initiate normal saline with new tubing, assess the client's status, notify the healthcare provider, and finally send the blood bag and specimens to the laboratory.
When an acute hemolytic transfusion reaction is suspected, the highest priority is to limit the client's exposure to the offending agent by stopping the transfusion immediately. Next, the nurse must maintain a patent IV line for emergency drugs by using normal saline and completely new tubing, avoiding the accidental bolus of remaining incompatible blood. After stabilizing the IV site, the nurse conducts a rapid assessment of vital signs and cardiopulmonary status to gather critical data. This data is then communicated to the healthcare provider. Finally, as a follow-up action, the nurse collects necessary specimens and returns the blood products to the lab for analysis.
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Anahtar Kavram
Management of a suspected acute hemolytic transfusion reaction requires immediate cessation of the blood product, maintenance of IV access using new tubing, and rapid clinical assessment prior to provider notification.