Ten minutes after a red blood cell transfusion begins, a client develops chills and low back pain. For each finding or action, select the best classification.
Matrix
Choose your responses, then check the answer.
Explanation
Chills and low back pain shortly after transfusion begins are reaction cues. Stop the transfusion, assess ABCs and vital signs, maintain IV access with normal saline and new tubing per protocol, notify the provider and transfusion service, verify identities, and preserve required specimens and equipment.
Quick answer Recognize the acute reaction cue, stop the transfusion, assess and escalate, maintain IV access with normal saline and new tubing per protocol, and notify the transfusion service while preserving evidence for investigation.
Why this is correct Chills and low back pain within minutes of starting red blood cells can signal a serious reaction. Continued exposure must end while the client is stabilized and the component, labels, tubing, and required samples are evaluated.
Easy analogy or mental picture Close the source first, keep a clean rescue line open, then preserve the trail needed to determine what happened.
Memory hook Stop, assess, saline with new tubing, notify, verify, preserve.
NCLEX decision rule For a suspected transfusion reaction, stop the blood before doing investigative steps. Follow the facility and transfusion-service protocol for IV fluid, identity checks, samples, and disposition of the unit and set.
Why the other choices are wrong Restarting without authorization can re-expose the client. Discarding the bag and tubing removes materials needed for reaction investigation.
Source
1AABB Circular of Information for Blood and Blood Components
22026 NCLEX-RN Test Plan
The nurse suspects an acute transfusion reaction and follows the facility's transfusion-reaction protocol. Emergency assessment and preservation of the blood component and administration set support both client safety and the investigation.
Acute transfusion reaction — An adverse clinical event occurring during or soon after blood-component administration that requires prompt assessment and investigation.
Transfusion service — The laboratory service that selects and issues blood components and coordinates transfusion-reaction investigation.
Postreaction specimen — A patient blood sample collected after a suspected reaction according to protocol for laboratory evaluation.