Question

A male client who was in a motor vehicle collision yesterday is receiving a unit of packed red blood cells. When half of the unit is infused, the client reports lower back pain, and the nurse observes a fine rash over his chest and back. Which intervention should the nurse implement?

A) Stop the blood transfusion immediately.
B) Assess for signs of fluid overload.
C) Administer an antihistamine.
D) Document the findings as an expected reaction.

Answer 1

If a client receiving a blood transfusion reports lower back pain and develops a rash, the transfusion must be stopped immediately. These are signs of a possible hemolytic transfusion reaction, which requires prompt intervention to prevent serious complications.

Step-by-step explanation:

The correct intervention when a male client reports lower back pain and displays a fine rash over his chest and back during a blood transfusion is A) Stop the blood transfusion immediately. These symptoms may indicate a hemolytic transfusion reaction (HTR), which is a serious and potentially life-threatening response to incompatible blood. HTR occurs when the body's immune system attacks transfused red blood cells due to incompatibility, leading to symptoms like fever, chills, back pain, rashes, and even more severe complications such as shock, renal failure, or death.

When half of the unit of packed red blood cells is infused, and the client shows these symptoms, the transfusion must be stopped to prevent further harm. Following cessation of the transfusion, further assessments and treatments as per hospital protocol should be initiated, which often include maintaining a patent intravenous line with saline, monitoring vital signs, informing the blood bank and the physician, and collecting required blood samples for investigation.