Final answer:
In an acute hemolytic reaction, a nurse must stop the blood transfusion, monitor vital signs, and notify the healthcare provider immediately. These actions are critical to prevent further harm and manage the patient's condition effectively.
Step-by-step explanation:
When a client is experiencing an acute hemolytic reaction during a blood transfusion, there are critical actions that a nurse must take to ensure patient safety. The correct steps include:
- Stop the blood transfusion immediately to prevent further hemolysis.
- Monitor vital signs closely, as changes can indicate the severity of the reaction and guide subsequent treatment.
- Notify the healthcare provider without delay, as they need to assess the patient and may order additional treatments to manage the reaction.
Administering pain medication is not the primary action during an acute hemolytic transfusion reaction but may be considered later once the initial, life-threatening issues are addressed and pain is assessed.