NCLEX-RNPharmacological and Parenteral TherapiesMedium
Ten minutes after a blood transfusion is started, a client reports lower back pain and chills. The nurse notes a temperature increase from 37.0°C to 38.6°C and dark urine. Which action should the nurse take first?
- AAdminister acetaminophen and continue the transfusion as ordered
- BSlow the transfusion rate and monitor vital signs every 15 minutes
- CNotify the blood bank at the end of the transfusion to report the reaction
- DStop the transfusion immediately and keep the IV line open with normal saline
Show answer & explanationAnswer & explanation
Correct answer: D. Stop the transfusion immediately and keep the IV line open with normal saline
Fever, chills, back pain, and dark urine within minutes of starting a transfusion are classic signs of an acute hemolytic transfusion reaction, a life-threatening emergency. The nurse's first action is to stop the transfusion immediately, keep the IV open with normal saline using new tubing, and notify the provider and blood bank.
Why the other options are wrong
- A. Continuing the transfusion risks worsening hemolysis and organ damage.
- B. Slowing rather than stopping the transfusion allows continued exposure to incompatible blood.
- C. Notification must occur immediately, not after the transfusion is completed.
Acute Hemolytic Transfusion Reaction
A life-threatening reaction to ABO-incompatible blood causing fever, chills, back pain, and dark urine, typically within the first 15-50 mL infused.
- First action: stop transfusion immediately
- Keep IV open with 0.9% normal saline via new tubing
- Notify provider and blood bank; return blood bag and send urine/blood samples
Memory trick: 'STOP first, ask questions later' when transfusion reaction is suspected