Fifteen minutes after a packed red blood cell transfusion begins, a client reports chills, back pain, and shortness of breath. Which action has priority?
1Slow the transfusion rate and reassess the client for symptom resolution in 15 minutes.
2Stop the transfusion and maintain IV access with 0.9% sodium chloride using new tubing.✓ Correct answer
3Collect a urine specimen for hemoglobinuria testing before changing the IV infusion tubing.
4Administer acetaminophen 650 mg orally and continue the transfusion as prescribed.
Explanation
Chills, back pain, and shortness of breath soon after transfusion begins suggest an acute transfusion reaction. The nurse should stop the transfusion immediately and maintain IV access with normal saline using new tubing, then notify the provider and blood bank according to policy.
Clinical Judgment When a transfusion reaction is suspected, prevent more blood from entering the client before collecting secondary data.
Memory Tip STOP blood, keep vein open with saline, notify, send blood and tubing per policy.
KR vs US NCLEX prioritizes immediate interruption of the blood product and a new saline line for safety.
Clinical Practice GuideOpen RN blood product guidance states that signs of transfusion reaction require stopping the transfusion and starting normal saline with new primed tubing according to policy.
CautionDo not flush through the existing blood tubing because remaining blood could enter the client.
Transfusion Reaction — An adverse response during or after blood product administration that can include fever, chills, back pain, dyspnea, hypotension, or hives.
Normal Saline — 0.9% sodium chloride, the standard compatible IV fluid used with blood products.
Blood Bank — The transfusion service that supports reaction workup, product tracking, and compatibility investigation.