A client who has received 50 mL of a unit of whole blood complains of low back pain. In response to this client’s symptom, a nurse should first: A. Reposition the client B. Assess the pain further C. Administer an analgesic D. Stop the blood transfusion *
The correct answer and explanation is:
The correct answer is: D. Stop the blood transfusion
Explanation:
When a client receiving a blood transfusion reports low back pain, this is a red flag symptom that may indicate a serious transfusion reaction, such as an acute hemolytic transfusion reaction. This type of reaction can be life-threatening and requires immediate intervention.
Why stop the transfusion first?
- The priority in nursing care is client safety. Continuing a transfusion when a serious reaction is suspected can worsen the client’s condition.
- Low back pain, along with symptoms like chills, fever, hypotension, flushing, and hematuria, is often an early sign of red blood cell destruction and kidney involvement.
- Stopping the transfusion immediately prevents further administration of the offending blood product, which could exacerbate the reaction.
Why not just assess or give analgesics first?
- Although assessing the pain (option B) is important, the immediate priority is to stop the transfusion to prevent further harm.
- Administering analgesics (option C) without stopping the transfusion risks masking symptoms and delaying diagnosis of a serious complication.
- Repositioning the client (option A) does not address the potential life-threatening cause of the symptom.
Next steps after stopping the transfusion:
- Keep the IV line open with normal saline using new tubing.
- Notify the healthcare provider and blood bank immediately.
- Monitor vital signs and assess for other symptoms of transfusion reaction.
- Collect required samples (blood and urine) as ordered to evaluate the reaction.
- Provide supportive care and prepare for possible emergency interventions.
Summary:
In any suspected transfusion reaction, the first and most crucial nursing action is to stop the transfusion immediately. Low back pain during blood transfusion is an early sign of a serious reaction, so prompt intervention can prevent severe complications and save the client’s life.