Medical Surgical Critical Care Blood Administration #3

Question

The nurse is starting a client’s 3rd unit of PRBCs. The client begins complaining of severe back pain, becomes apprehensive, and VS: T 100.9F, P 126, RR 28, BP 80/54. Which intervention should the nurse perform as priority?

Answers

  1. Administer tylenol and benadryl and continue the infusion.
    • Rationale:

      This answer is not correct because administration of tylenol and benadryl are used as premedication for clients who have had transfusion reactions and for febrile blood reactions.

  2. Slow the infusion because the client is in circulatory overload.
    • Rationale:

      This answer is not correct because with circulatory overload, the client would experience crackles in the lungs, restlessness, shortness of breath, dyspnea, and jugular vein distention.

  3. Stop the infusion because the client is having a hemolytic reaction.
    • Rationale:

      This answer is correct because the client is having a hemolytic blood transfusion reaction and the nurse must stop the infusion immediately.

  4. Stop the infusion because the client is having an anaphylactic reaction.
    • Rationale:

      This answer is not correct because when a client has an anaphylactic reaction, the client will experience wheezing, hives, and hypotension.

Overview

When a client has a hemolytic reaction, the client complains of lower back pain, is apprehensive, spikes a fever, has tachycardia, and hypotension. The priority is to stop the infusion, call the health care provider, get labs drawn, and collect a urine specimen.

Explanation

Learning Outcomes

When a client has a hemolytic reaction, the client’s immune system destroys the red blood cells administered during the transfusion. This process of destruction is called hemolysis. The client’s symptoms may include lower back pain, apprehension, fever, tachycardia, and hypotension. The priority is to stop the infusion, call the health care provider, get labs drawn, and collect a urine specimen. Treatment of such a reaction is aimed at protecting the client’s renal function, so IV fluids will be administered, intake and output will be closely monitored to ensure urine output is 100 ml/hr, and diuretics will be administered.

Test Taking Tip

Know the priority interventions for each type of transfusion reaction.

Video Rationale