The nurse suspects that the patient is experiencing a blood transfusion reaction. The nurse stops the infusion but is concerned about losing the IV line if blood clots in the catheter. The nurse should:

Question

a. replace the entire transfusion line with a new set primed with normal saline.
b. turn off the blood and turn on the normal saline infusion to flush the tubing.
c. discontinue the IV and start a new IV of lactated Ringer's in the other extremity.
d. maintain the patency of the current IV line by hanging a new IV bag of D5W.

Answer 1

A
Remove the blood component and tubing containing the blood product. Replace them with new primed tubing with a container of 0.9% sodium chloride (normal saline). Connect tubing to hub of IV catheter. Do not turn off the blood and simply turn on the 0.9% sodium chloride (normal saline) that is connected to the Y-tubing infusion set. This would cause blood remaining in the Y-tubing to infuse into the patient. Even a small amount of mismatched blood can cause a major reaction. Keep the IV site in case it becomes difficult to start another. Maintain a patent IV line using 0.9% normal saline.