Final answer:
A nurse must respond rapidly to a transfusion reaction by stopping the transfusion, notifying medical staff, checking patient identity and blood compatibility, monitoring vitals, collecting samples for the lab, initiating prescribed treatment, administering fluids and vasopressors if needed, and providing oxygen therapy to mitigate a hemolytic transfusion reaction and prevent severe complications.
Step-by-step explanation:
When a patient experiences a transfusion reaction, appropriate nursing interventions are critical. The following steps should be taken immediately:
- Stop the transfusion and keep the intravenous line open with saline to maintain venous access.
- Notify the physician and the blood bank immediately to report the reaction.
- Recheck the patient's identity and blood compatibility to confirm that the correct blood was given.
- Monitor vital signs frequently to assess the severity of the reaction and the patient's response to intervention.
- Collect required blood and urine samples to detect hemolysis and send these to the laboratory.
- Initiate treatment as prescribed, which may include antihistamines, antipyretics, and corticosteroids to manage symptoms.
- Prepare to administer intravenous fluids and vasopressors if hypotension occurs.
- Administer oxygen therapy if the patient exhibits dyspnea or hypoxia.
These steps are crucial to mitigate the adverse effects of a hemolytic transfusion reaction (HTR) and to prevent the occurrence of life-threatening complications such as shock and multi-organ failure.