Final answer:
In the event of a patient experiencing symptoms of a hemolytic transfusion reaction, such as lower back pain and a rash during a blood transfusion, the nurse should immediately stop the transfusion and replace it with normal saline to maintain blood pressure and circulation. Emergency care should be summoned, and the situation handled according to hospital protocol.
Step-by-step explanation:
The scenario described suggests that the male client may be experiencing a hemolytic transfusion reaction (HTR), which is a serious and potentially life-threatening condition. It occurs when the patient receives a transfusion with incompatible blood types. Symptoms of HTR include lower back pain, rashes (like the fine rash observed), fever, chills, and hemoglobinuria. Immediate intervention is required to prevent further complications.
The appropriate nursing intervention in this situation would be to stop the blood transfusion immediately and replace it with an infusion of normal saline. This is critical to maintain the patient's blood pressure and circulation while stopping exposure to the incompatible blood. Further, emergency medical care should be summoned, and the situation reported as per the hospital's protocol which often involves sending the remaining blood product and a blood sample back to the laboratory for rechecking of the patient's blood type and the transfused blood type along with tests for hemolysis.
Applying an anti-itch ointment or instructing the patient to avoid certain positions would not address the underlying cause or the immediate risk of the reaction. While glucocorticoids may be used in some allergic reactions, in the case of a suspected HTR, the priority is to stop the transfusion and provide supportive care as needed. Lastly, the medical team will need to monitor the patient closely for any signs of anaphylaxis or shock, which can occur with HTRs.