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Zorluk: ZorPharmacological and Parenteral Therapies

A hospitalized client with severe anemia is receiving a transfusion of packed red blood cells. Fifteen minutes after the procedure begins, the client reports acute lower back pain, sudden chills, and a sensation of chest tightness. The telemetry monitor indicates a rapid onset of sinus tachycardia. The nurse immediately halts the transfusion. What is the most critical subsequent action for the nurse to execute?

  1. Detach the transfusion tubing from the catheter hub and connect a newly primed 0.9% sodium chloride infusion set.Cevap
  2. B
    Push a bolus of normal saline directly through the existing Y-site port to ensure the vascular access remains patent.
  3. C
    Obtain a stat urine specimen and venous blood sample to send to the laboratory for hemolysis evaluation.
  4. D
    Calculate the precise volume of the infused blood product to complete the fluid intake documentation before notifying the provider.

Cevap

Detach the transfusion tubing from the catheter hub and connect a newly primed 0.9% sodium chloride infusion set.
When a client experiences an acute hemolytic reaction, the absolute priority after stopping the transfusion is to maintain vascular access for emergency medications and fluid volume replacement to prevent acute kidney injury and cardiovascular collapse. This must be done by completely disconnecting the blood tubing at the hub and attaching a new, sterile IV line primed with 0.9% normal saline. This prevents the blood remaining in the old tubing from being inadvertently flushed into the client.

Adım Adım Çözüm

1
Analyze the client's clinical presentation.
The symptoms (lower back pain, chills, chest tightness, tachycardia) occurring 15 minutes into a transfusion indicate an acute hemolytic reaction.
Early recognition of a life-threatening transfusion reaction is essential to halt further administration of the incompatible antigen.
2
Identify the immediate priority after stopping the infusion.
The nurse must maintain vascular access to treat potential shock and prevent acute kidney injury, but must avoid administering any more of the reactive blood.
During an acute hemolytic reaction, the kidneys are at high risk of failure due to hemoglobinuria. Vigorous intravenous hydration is required.
3
Select the safest method to maintain vascular access.
The nurse must disconnect the blood tubing entirely and attach new, sterile tubing primed with 0.9% normal saline.
Using the existing tubing would flush the remaining blood product into the client, exacerbating the hemolytic reaction.

Anahtar Kavram

Blood Transfusion Reactions and IV Administration Safety
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Konular

Pharmacological and Parenteral Therapies

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