Fifteen minutes after a packed red blood cell transfusion be… | MyMerci
Complications of ProceduresROR
Question
Fifteen minutes after a packed red blood cell transfusion begins, a client reports chills and back pain. The temperature rises from 37.1 C to 38.4 C. What should the nurse do first?
1Slow the transfusion and recheck the temperature in 1 hour.
2Give acetaminophen and continue the transfusion.
3Stop the transfusion and maintain IV access with normal saline using new tubing.✓ Correct answer
4Document the findings as expected during the first 15 minutes.
Explanation
Fever, chills, and back pain shortly after transfusion begins suggest a transfusion reaction. The nurse should stop the transfusion immediately, keep IV access open with normal saline using new tubing, and follow reaction protocol. Continuing the blood can worsen the reaction.
In-depth explanation
Clinical Judgment Suspected transfusion reaction means stop the blood first.
Memory Tip Stop blood, keep vein open.
Clinical scenario
Clinical Practice Guide Transfusion monitoring is especially important during the first minutes and includes temperature, chills, pain, dyspnea, and vital signs.
Caution Do not restart blood until the reaction is evaluated according to protocol.
Key concepts
Transfusion Reaction — An adverse response to blood product administration.
Packed Red Blood Cells — A blood component used to increase oxygen-carrying capacity.
Normal Saline — The compatible IV fluid used to maintain access during transfusion reaction management.