An adult client is receiving a transfusion of packed red blood cells (PRBCs) through a peripheral intravenous catheter for symptomatic anemia. Approximately minutes after the transfusion begins, the client reports sudden lower back pain, chills, and severe shortness of breath. The nurse observes that the client's urine in the bedside drainage bag has turned a dark, reddish-brown color. Which of the following is the most appropriate initial nursing action?
- AInstruct the unlicensed assistive personnel to immediately obtain a complete set of vital signs.
- BAdminister the prescribed as-needed acetaminophen and slow the transfusion rate to mL/hr.
- Stop the blood transfusion immediately and maintain intravenous access with normal saline using new tubing.Cevap
- DRecalculate the drip rate to infuse the remaining blood product over a maximum of hours.
Cevap
The nurse must immediately stop the blood transfusion and maintain intravenous access with normal saline using completely new tubing.
The client is exhibiting the hallmark signs of an acute hemolytic transfusion reaction (lower back pain, hemoglobinuria, chills, dyspnea). This is a life-threatening medical emergency typically caused by ABO incompatibility. The absolute first priority is to stop the transfusion to prevent further exposure to the incompatible blood. The nurse must then maintain the intravenous line with normal saline using entirely new tubing, because flushing the existing blood tubing would force more incompatible red blood cells into the client's circulation.
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Anahtar Kavram
Management of Acute Hemolytic Transfusion Reactions
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