A nurse is caring for a client. Exhibits For each potential nursing intervention, click to specify if the intervention is anticipated or contraindicated for the client.

Rationale: Stop transfusion: The client is showing signs of a serious transfusion reaction such as fever, chills, back pain, and hypotension. Immediately stopping the transfusion prevents further infusion of incompatible blood, which could worsen hemolysis and lead to shock or kidney failure. Flush blood transfusion tubing: Flushing the existing blood tubing with saline could push more incompatible blood cells into the circulation. This can intensify the reaction and increase the risk of complications. Instead, new IV tubing with normal saline should be used if further IV access is needed. Notify blood bank: The blood bank must be informed to initiate an investigation, verify blood compatibility, and conduct testing to determine the cause of the reaction. This helps prevent further occurrences and ensures patient safety. Notify primary physician: The physician needs to be informed promptly to provide additional orders, such as fluid resuscitation, lab tests, or medications to stabilize the client. Immediate collaboration is essential to manage the adverse event effectively. Return blood and tubing to blood bank: Returning the blood product and used tubing allows the blood bank to analyze the unit for errors or contamination. This is necessary for confirming the transfusion reaction and documenting the incident. Administer IV diphenhydramine: Diphenhydramine may be used to reduce symptoms such as itching or chills if an allergic component is suspected. It is often part of the initial response while further evaluation and treatment are underway. Administer oxygen: The client’s oxygen saturation has dropped, and respirations are rapid and labored. Administering oxygen supports tissue oxygenation and addresses hypoxia during this acute reaction, which may compromise respiratory function.