A client is receiving a blood transfusion. Fifteen minutes after the transfusion starts, the nurse notes a drop in blood pressure from 110/70 to 84/50 mm Hg. The client reports "feeling a little cold." Based on this assessment, in what order should the nurse complete the following actions? All options must be used.

Question

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It is important for the nurse to remain with the client for 15 minutes after starting a blood transfusion to monitor for signs of a reaction. These signs include fever, chills, nausea, vomiting, pruritus, hypotension, decreased urine output, back pain, and dyspnea. The client may report a variety of symptoms ranging from none to a feeling of impending doom. If signs of a transfusion reaction occur, the nurse should: Stop the transfusion immediately (Option D). Using new tubing, infuse normal saline to keep the vein open (Option E). Continue to monitor hemodynamic status and notify the health care provider and blood bank. Administer any emergency or prescribed medications to treat the reaction; these may include vasopressors, antihistamines, steroids, or IV fluids (Option A). Collect a urine specimen to be assessed for a hemolytic reaction (Option B). Document the occurrence and send the remaining blood and tubing set back to the blood bank for analysis (Option C). Educational objective: If signs or symptoms of a blood transfusion reaction occur, the nurse should stop the infusion immediately and use new tubing to keep the vein open with normal saline. The nurse should continue to monitor the client's hemodynamic status, and administer prescribed drugs. The nurse should also collect a urine specimen to be assessed for a hemolytic reaction.

A Client Is Receiving a Blood Transfusion