NCLEX-RNReduction of Risk PotentialMedium
Fifteen minutes into a packed red blood cell transfusion, a client reports low back pain and chills, with a temperature increase to 101.2°F (38.4°C), HR 118/min, and reddish-tinged urine. Which action should the nurse take first?
- AStop the transfusion and infuse normal saline through new tubing
- BSlow the infusion rate and continue to monitor
- CGive an antipyretic and reassess in 30 minutes
- DAdminister diphenhydramine and continue the transfusion
Show answer & explanationAnswer & explanation
Correct answer: A. Stop the transfusion and infuse normal saline through new tubing
Fever, chills, back pain, and hemoglobinuria during a transfusion indicate an acute hemolytic transfusion reaction. The first priority is to stop the transfusion immediately, maintain IV access with normal saline through new tubing, and notify the provider and blood bank.
Why the other options are wrong
- B. Slowing the infusion still allows continued exposure to incompatible blood.
- C. Treating symptoms without stopping the transfusion delays essential emergency management.
- D. Continuing the transfusion after signs of a hemolytic reaction risks severe complications, including renal failure.
Acute Hemolytic Transfusion Reaction
A serious reaction caused by ABO blood incompatibility, presenting with fever, chills, back pain, and hemoglobinuria shortly after transfusion begins.
- Stopping the transfusion is the first priority action
- Maintain IV access with normal saline via new tubing
- Notify provider and blood bank; send blood bag/tubing for analysis
Memory trick: STOP first, ask questions later