A client receiving a blood transfusion develops anxiety and low back pain. After stopping the transfusion, what action by the nurse is most important?
a. Documenting the events in the client's medical record
b. Double-checking the client and blood product identification
c. Placing the client on strict bedrest until the pain subsides
d. Reviewing the client's medical record for known allergies
ANS: B
This client had a hemolytic transfusion reaction, most commonly caused by blood type or Rh incompatibility. The nurse should double-check all identifying information for both the client and blood type. Documentation occurs after the client is stable. Bedrest may or may not be needed. Allergies to medications or environmental items is not related.
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