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512\. A hospitalized client receives a transfusion of whole blood. The client suddenly develops chest pain, fever and chills. The nurse suspects a hemolytic transfusion reaction. Which is the priority nursing intervention? A. Notify the physician. B. Flush the line with \(\mathrm{D}_5 \mathrm{NS}\). C. Stop the infusion and maintain the IV line with normal saline. D. Give the client the Benadryl (diphenhydramine) available as a prn order.The answer is C. Hemolytic transfusion reactions are caused by a reaction from antibodies in the recipient blood reacting to the donor's blood protein. This can lead to serious consequences and may be fatal. Stopping the infusion is critical to reduce the source of the reaction. It is essential that the IV line be kept open for emergency access. The physician needs to be notified but it is not the priority action. Flushing the line with dextrose will cause the blood to clot. This is not an allergic reaction so Benadryl will not resolve the problem.

Step by step solution

01

Identify the Symptoms

Recognize that the client developed chest pain, fever, and chills during the blood transfusion, indicating a possible hemolytic transfusion reaction.

02

Priority Intervention

Determine that stopping the infusion is critical to reducing the source of the reaction.

03

Maintaining Access

Ensure that the IV line is maintained with normal saline to keep it open for emergency access.

04

Importance of Sequence

Understand that while notifying the physician is important, it is not the immediate priority. The infusion must be stopped first.

05

Understanding Other Options

Recognize that flushing the line with \(\text{D}_5 \text{NS}\) will cause the blood to clot, and giving Benadryl will not address the hemolytic reaction since it is not an allergic reaction.

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Key Concepts

These are the key concepts you need to understand to accurately answer the question.

nursing intervention

When a patient experiences symptoms like chest pain, fever, and chills during a blood transfusion, it can be a sign of a hemolytic transfusion reaction. In this critical scenario, the nurse’s priority intervention is to stop the transfusion immediately. This action helps to minimize the patient’s exposure to the harmful blood components causing the reaction. The next crucial step is to maintain the IV line with normal saline to keep it open for emergency access. This ensures that any necessary medications or treatments can be administered quickly. It's important to note that while notifying the physician is necessary, it should be done after stopping the transfusion. Providing diphenhydramine (Benadryl) would not be effective in this case, as it addresses allergic reactions rather than hemolytic reactions.

blood transfusion reactions

Blood transfusion reactions can vary in severity and type. The hemolytic transfusion reaction is one of the most serious and occurs when the recipient's immune system attacks the donor blood cells. Symptoms can include chest pain, fever, chills, back pain, dark urine, and a rapid heartbeat. It is critical to recognize these symptoms quickly as the condition can progress rapidly and become life-threatening. Hemolytic reactions are usually caused by incompatible blood types or Rh factors. Other less severe reactions might include febrile non-hemolytic transfusion reactions or allergic reactions, which are typically managed with medications like antipyretics and antihistamines respectively, but these do not address the root cause of hemolytic reactions.

emergency response protocol

In the event of a hemolytic transfusion reaction, an established emergency response protocol is essential. This protocol ensures that care is immediate, systematic, and effective. The key steps include:

• Stop the transfusion immediately to prevent further hemolysis.
• Maintain the IV line with normal saline to provide a route for emergency treatments.
• Notify the physician and follow their orders promptly.
• Collect blood and urine samples to send for analysis. This helps to identify the cause and extent of the reaction.
• Provide supportive care, such as administering oxygen and monitoring vital signs closely.

Having a well-structured protocol decreases the time to treatment, improves outcomes, and ensures that all healthcare staff are aware of their roles during the emergency.