A client receiving a blood transfusion begins complaining of lower back pain and dyspnea. The nurse should first:
ExplanationThe client is exhibiting signs of a hemolytic blood transfusion reaction. The nurse stops the blood transfusion to prevent further
reactions and notifies the physician before further therapy can be initiated. Once the infusion is discontinued, the nurse removes
and changes the tubing (because blood remains in the tubing) and infuses normal saline in order to keep the IV line open. The
transfusion must be stopped, not slowed. The first step is to stop the transfusion; the nurse can take vital signs after (or while, if assistance is available) notifying the physician.
