A nurse is monitoring a client who is receiving an intravenous transfusion of packed red blood cells. Ten minutes after the transfusion begins, the client develops sudden severe lower back pain, tachycardia, and dyspnea. Place the following nursing interventions in the correct order of priority to mitigate further physiological risk to the client. (Arrange the steps from first action to last action.)
- 1Stop the blood transfusion immediately.
- 2Disconnect the blood tubing and initiate an infusion of 0.9% sodium chloride through new intravenous tubing.
- 3Assess the client's vital signs, respiratory status, and hemodynamic stability.
- 4Notify the prescribing healthcare provider and the blood bank of the suspected reaction.
- 5Send the discontinued blood bag, tubing, and attached labels to the blood bank for analysis.
Cevap
The correct sequence is to first stop the transfusion, then maintain intravenous access with normal saline using new tubing, followed by assessing the client's current status, notifying the provider and blood bank, and finally returning the discontinued blood products for laboratory analysis.
The priority in any acute adverse event is to remove or stop the offending agent immediately to reduce physiological risk. Once stopped, maintaining intravenous access is critical for resuscitation. Assessment must follow to gather current data before calling the provider, ensuring the nurse can provide an accurate SBAR report. Administrative and follow-up tasks, such as returning the bag to the laboratory, always occur last after the client is stabilized.
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Prioritization of Care in Acute Transfusion Reactions