A client develops signs of an acute hemolytic reaction shortly after a red-blood-cell transfusion begins. Complete the immediate nursing response.
Drop-down Cloze
Choose your responses, then check the answer.
Explanation
The timing and combination of pain, chills, hypotension, tachycardia, and dark urine suggest an acute hemolytic transfusion reaction. The nurse must stop the transfusion immediately, maintain venous access with compatible normal saline through new tubing according to policy, assess and support airway, breathing, circulation, and notify the provider and transfusion service. The nurse rechecks client and component identification and sends the implicated unit, tubing, and required blood or urine specimens according to protocol. The transfusion must not be restarted, and renal perfusion, urine output, coagulation, electrolytes, and hemodynamics require close monitoring.
Correct Answer Stop the blood immediately, support circulation through separate compatible tubing, and activate the transfusion-reaction investigation.
Why It Fits Acute pain, chills, shock, and hemoglobinuria within minutes are consistent with intravascular hemolysis.
Clinical Picture Keeping intravenous access does not mean flushing residual incompatible blood from the blood tubing into the client.
Memory Link Reaction means stop the product, support the person, save and investigate the unit.
NCLEX Rule Any serious suspected transfusion reaction requires immediate cessation, clinical stabilization, notification, identification checks, and laboratory investigation.
Why the Alternatives Fail Slowing the unit, giving an antipyretic first, or restarting after symptoms improve can increase exposure to the harmful component.
Sources
1Australian Red Cross Lifeblood Acute Haemolytic Reactions
2CDC Clinical Guidance for Bacterial Contamination and Blood Safety
3NCSBN 2026 NCLEX-RN Test Plan
Medical unitFifteen minutes after packed red blood cells are started, the client reports sudden flank and back pain, chills, and nausea. Blood pressure falls from 132/76 to 88/50 mm Hg, heart rate is 124/min, and dark red urine appears in the catheter tubing.
Acute hemolytic transfusion reaction — Rapid destruction of transfused red cells, often from incompatibility, causing systemic and renal complications.
Hemoglobinuria — Free hemoglobin in urine, which may produce dark red or brown urine during intravascular hemolysis.
Direct antiglobulin test — A laboratory test that detects immunoglobulin or complement attached to red blood cells.