A client is receiving a blood transfusion, The nurse observes that the client is experiencing flank and lower back pain. Which of the following orders does the nurse anticipate receiving?

A) Having 2 RNs ensure the blood product is properly labeled and matches the client’s identification:
Two registered nurses must independently verify that the blood product matches the patient's identification and that it is properly labeled. This is a critical safety measure to prevent errors, such as mismatched blood transfusions, which can lead to severe complications like hemolytic reactions. Proper verification before administration is a standard safety protocol in blood transfusion procedures.

B) Ensuring that the client signed a consent form for receiving blood transfusions beforehand:
Obtaining informed consent is a vital legal and ethical step before administering a blood transfusion. The nurse must ensure that the patient understands the potential risks and benefits of the procedure and has signed a consent form prior to transfusion. Without consent, the transfusion cannot legally be performed. This is a key part of patient rights and nursing responsibilities.

C) Preparing a primary and secondary IV tubing:
For blood transfusions, only blood administration tubing should be used, which typically includes a filter to prevent the infusion of any debris or clots. Using regular IV tubing (primary and secondary) for blood administration is not recommended, as it may not have the necessary filter and could potentially introduce contaminants. Blood should always be administered with tubing specifically designed for that purpose.

D) Obtaining a bag of 0.9% sodium chloride:
Normal saline is typically used as the solution to flush the IV line before and after the transfusion. It is compatible with blood products and helps to prevent clotting or reactions in the line. This is an essential step to ensure safe and effective blood administration.

A. Intramuscular epinephrine:
Intramuscular epinephrine is typically used in cases of anaphylactic reactions, which present with symptoms such as difficulty breathing, swelling, hives, and hypotension. Flank and lower back pain are not typical signs of an anaphylactic reaction during a blood transfusion. Instead, flank pain may suggest a hemolytic reaction, which involves the destruction of red blood cells, not an allergic or anaphylactic response. Thus, epinephrine would not be the first-line treatment for this situation.

B. Intravenous corticosteroids:
Intravenous corticosteroids are often used for inflammatory reactions, such as in cases of autoimmune diseases or severe allergic reactions. While corticosteroids might be used for certain types of transfusion reactions, they are not the primary treatment for hemolytic reactions (which could cause flank and lower back pain). The primary goal in a transfusion reaction with flank pain is to manage potential hemolysis and prevent kidney damage, which would be addressed through hydration and other supportive measures.

C. High volume IV fluids:
High-volume IV fluids are the most appropriate immediate intervention for a client who is experiencing flank and lower back pain during a blood transfusion, which are signs of a potential hemolytic reaction. Hemolysis, or the breakdown of red blood cells, can lead to kidney injury, so increasing fluid volume helps flush the kidneys, promote diuresis, and reduce the risk of kidney damage. The fluids also help to dilute any hemoglobin that is released into the bloodstream, supporting the kidneys' ability to filter it out. This is the priority intervention in this scenario.

D. PO diphenhydramine:
Oral diphenhydramine is used for allergic reactions, such as mild reactions involving itching, rashes, or hives, but it is not appropriate for managing more severe transfusion reactions, such as hemolytic reactions, that cause flank and lower back pain. Diphenhydramine would not address the underlying issue of potential hemolysis and kidney injury. Therefore, it is not the correct intervention for this situation.