A patient is receiving a transfusion of packed RBCs. Ten minutes after the infusion begins, the patient reports low back pain and a headache. Place the actions in order (1–5) of importance of performance
A. ___ Stop the blood infusion.
B. ___ Notify the physician stat.
C. ___ Obtain vital signs and assess patient.
D. ___ Start the new 0.9% normal saline infusion.
E. ___ Prepare a new 0.9% normal saline infusion.
ANS:
A, C, B, E, D
Low back pain and headache can be symptoms of a transfusion reaction. If symptoms of a reaction are noted, the blood transfusion is immediately stopped and agency policy for a suspected transfusion reaction is followed. A normal saline infusion with new tubing is started to keep the vein patent. The physician and blood bank are immediately notified. A nurse remains with the patient for reassurance and monitoring of symptoms and vital signs. If a blood incompatibility is suspected, the unused blood and blood tubing are returned to the blood bank for testing. A series of blood and urine specimens are collected and sent to the laboratory for analysis. The physician's orders are followed to treat the patient's symptoms.
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