hard · NCLEX-RN Pharmacological and Parenteral Therapies
The nurse suspects an acute hemolytic transfusion reaction. Sequence the immediate nursing actions in the correct chronological order from first to last. Base the response on this specific EHR: "Patient Summary": "45-year-old female receiving a unit of packed red blood cells (PRBCs).", "Vital Signs": "Baseline: BP 118/74 mm Hg, HR 82/min, RR 16/min, T 37.0 C. At 15 minutes: BP 90/52 mm Hg, HR 122/min, RR 28/mi.
- Stop the blood transfusion immediately.
- Disconnect the blood administration tubing from the IV hub and connect a new infusion of 0.9% normal saline with new tubing.
- Obtain a complete set of vital signs and perform a focused cardiorespiratory assessment.
- Notify the primary healthcare provider and the hospital blood bank of the reaction.
- Return the remaining blood product, administration set, and completed transfusion reaction form to the blood bank.
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