NCLEX-PN® ExaminationPhysiological AdaptationEasy
A client with chronic kidney disease is receiving a blood transfusion. Thirty minutes into the transfusion, the client reports chills, back pain, and shortness of breath. The nurse observes dark urine and facial flushing. What is the nurse's immediate priority action?
- AStop the transfusion immediately and notify the physician.
- BAdminister a prescribed antihistamine.
- CSlow down the rate of the blood transfusion.
- DObtain a urine specimen for urinalysis.
Show answer & explanationAnswer & explanation
Correct answer: A. Stop the transfusion immediately and notify the physician.
The client's symptoms (chills, back pain, shortness of breath, dark urine, facial flushing) are classic signs of an acute hemolytic transfusion reaction, a life-threatening emergency. The immediate priority is to stop the transfusion to prevent further infusion of incompatible blood and notify the physician to initiate appropriate medical management.
Why the other options are wrong
- B. An antihistamine is not sufficient for an acute hemolytic reaction and does not address the underlying problem of incompatible blood.
- C. Slowing the transfusion will not stop the reaction and will continue to administer incompatible blood, worsening the client's condition.
- D. While a urine specimen will be needed later for analysis, it is not the immediate priority over stopping the transfusion.
Acute Hemolytic Transfusion Reaction
A severe, life-threatening transfusion reaction caused by incompatibility between donor and recipient blood, leading to rapid destruction of donor red blood cells.
- Occurs within minutes to hours of transfusion initiation.
- Symptoms: fever, chills, back pain, dyspnea, hypotension, dark urine, apprehension.
- Immediate action: Stop transfusion, maintain IV access with saline, notify blood bank and physician.
Memory trick: Bad Blood? Stop, Stay, and Notify!