Ten minutes after an infusion of packed red blood cells (PRBCs) is initiated through a central venous catheter (CVC), the client has shortness of breath and slight chest tightness. What initial actions would be appropriate for the nurse to complete? Select all that apply. A)Assess the client's breath sounds B)Flush the blood IV tubing with normal saline C)Notify the health care provider (HCP) D)Remove the CVC E)Stop the infusion of PRBCs

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Quizplus · Accepted Answer

Signs and symptoms of a blood transfusion reaction typically will occur within the first 15 minutes after initiation of the transfusion. These include shortness of breath, chest tightness, fever, back pain, anxiety, tachycardia, and hypotension. When a transfusion reaction is suspected, the first step is to stop the infusion (Option E). An infusion of normal saline is typically started. It is important that normal saline be administered through a different port of the CVC using new tubing or at the closest access point to the client. Flushing the blood in the IV tubing into the client will expose the client to more of the causative agent and increase complications from the transfusion reaction (Option B). The HCP must then be notified (Option C). Because the client has shortness of breath and chest tightness, an assessment of breath sounds is appropriate. Adventitious sounds could indicate bronchospasm or excess fluid in the lungs (Option A). (Option D) A CVC will not be discontinued due to the transfusion reaction. IV access will be required for administration of fluids and medications. Educational objective: If an adverse blood transfusion reaction is suspected, the first action is to stop the infusion. An infusion of normal saline through a different port for the CVC is typically started. A client assessment and notification of the HCP are also required.

Ten Minutes After an Infusion of Packed Red Blood Cells