Final answer:
The nurse should suspect a transfusion reaction based on assessment findings such as back pain, skin manifestations, headache, changes in vital signs, and anxiety.
Step-by-step explanation:
The nurse should suspect a transfusion reaction based on the following assessment findings:
- Back pain: Back pain may occur as a result of occlusion of blood vessels in the kidneys due to debris from damaged and destroyed red blood cells.
- Skin: Skin manifestations such as itching (pruritus) and hives (urticaria) may be present as a hypersensitivity reaction to incompatible blood transfusion.
- Headache: Headache may result from the inflammatory response triggered by a transfusion reaction.
- Vital Signs: Changes in vital signs, such as fever and low blood pressure (hypotension), may indicate an adverse transfusion reaction.
- Anxiety: Anxiety can be a psychological response to a transfusion reaction.