NCLEX-PN® ExaminationReduction of Risk PotentialHard
An LPN is monitoring a client receiving a blood transfusion. Which finding would require the nurse to immediately stop the transfusion?
- ATemperature increase from 98.6°F (37.0°C) to 99.2°F (37.3°C).
- BFlank pain and red-brown urine.
- CMild itching and a localized rash.
- DBlood pressure decrease from 120/80 mmHg to 110/70 mmHg.
Show answer & explanationAnswer & explanation
Correct answer: B. Flank pain and red-brown urine.
Flank pain and red-brown urine are classic signs of an acute hemolytic transfusion reaction, a severe and life-threatening complication that requires immediate cessation of the transfusion, maintenance of IV access, and notification of the provider.
Why the other options are wrong
- A. A temperature increase of less than 1°C (1.8°F) may not warrant immediate cessation, but warrants close monitoring. A febrile non-hemolytic reaction is usually indicated by a rise of 1°C or more.
- C. Mild itching and a localized rash could indicate a mild allergic reaction, which might require stopping the transfusion, but often can be managed with antihistamines while continuing the transfusion at a slower rate, under close observation.
- D. A slight drop in blood pressure could be due to various factors and may not immediately necessitate stopping the transfusion, but would require further assessment and monitoring. A significant drop would be concerning.
Acute Hemolytic Transfusion Reaction
A severe, life-threatening transfusion reaction caused by ABO incompatibility, leading to rapid destruction of red blood cells.
- Symptoms: fever, chills, flank pain, red-brown urine, hypotension, dyspnea
- Onset: typically within minutes of transfusion initiation
- Intervention: IMMEDIATELY stop transfusion, maintain IV, notify provider, send blood bag/tubing to lab
Memory trick: Blood Reactions: Don't Be BLIND to the Signs!