A client has severe anemia and will be receiving blood transfusions. T

A client has severe anemia and will be receiving blood transfusions. The nurse prepares and be-gins the infusion. Ten minutes after the infusion has begun, the client develops tachycardia, chills, and low back pain.

After stopping the transfusion, the nurse should:
1. Administer an antipyretic
2. Begin an infusion of epinephrine
3. Run normal saline through the blood tubing
4. Obtain and send a urine specimen to the laboratory

ANSWER

ANS: 4
After stopping the blood transfusion, the nurse should obtain and send a urine specimen to the laboratory to determine the presence of hemoglobin as a result of red blood cell (RBC) hemoly-sis. In an acute hemolytic reaction, management of the reaction does not include the administra-tion of an antipyretic. The nurse should be prepared to administer emergency drugs, such as diu-retics, per the health care provider’s order. The nurse should not turn off the blood and simply turn on the normal saline that is connected to the Y-tubing set. This would cause blood remaining in the Y-tubing to infuse into the client. Even a small amount of mismatched blood can cause a major reaction. The nurse should run normal saline directly into the IV line (not through the blood tubing).