Page 2412 - Saunders Comprehensive Review For NCLEX-RN

Priority Nursing Actions

Transfusion Reaction
1. Stop the transfusion.
2. Change the intravenous (IV) tubing down to the IV site and keep
the IV line open with normal saline.
3. Notify the primary health care provider (PHCP) and blood bank.
4. Stay with the client, observing signs and symptoms and
monitoring vital signs as often as every 5 minutes.
5. Prepare to administer emergency medications as prescribed.
6. Obtain a urine specimen for laboratory studies (perform any
other laboratory studies as prescribed).
7. Return blood bag, tubing, attached labels, and transfusion record
to the blood bank.
8. Document the occurrence, actions taken, and the client’s
response.

Reference

Perry et al. (2018), pp. 803-805.

H. Circulatory overload
1. Description: Caused by the infusion of blood at a rate
too rapid for the client to tolerate
2. Assessment
a. Cough, dyspnea, chest pain, and
wheezing on auscultation of the lungs
b. Headache
c. Hypertension
d. Tachycardia and a bounding pulse
e. Distended neck veins

3. Interventions

a. Slow the rate of infusion.
b. Place the client in an upright position,
with the feet in a dependent position.
c. Notify the PHCP.
d. Administer oxygen, diuretics, and
morphine sulfate, as prescribed.
e. Monitor for dysrhythmias.
f. Phlebotomy also may be a method of
prescribed treatment in a severe case.
I. Septicemia
1. Description: Occurs with the transfusion of blood that
is contaminated with microorganisms
2. Assessment
a. Rapid onset of chills and a high fever
b. Vomiting
c. Diarrhea
d. Hypotension
e. Shock

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