hard · NCLEX-RN pharmacology
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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