A 58-year-old client with anemia from gastrointestinal bleeding is receiving the first unit of packed red blood cells. Pretransfusion vital signs were temperature 36.9 C (98.4 F), heart rate 88/min, and blood pressure 128/74 mm Hg. Ten minutes after the transfusion starts, the client reports chills, low back pain, and shortness of breath. Temperature is now 38.5 C (101.3 F), heart rate 124/min, blood pressure 86/48 mm Hg, and oxygen saturation 93% on room air. Lung sounds are clear, neck veins are flat, and no rash, hives, or wheezing is present. Dark red-brown urine appears in the catheter drainage bag. Complete the diagram by selecting the condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.

Quick answer
Acute hemolytic transfusion reaction; stop the transfusion and keep the bag, infuse normal saline through new tubing, and monitor hourly urine output and color along with blood pressure and heart rate.

Why this is correct
Fever alone could be a febrile nonhemolytic reaction, but this client also has back pain, hypotension, and dark urine, which signal intravascular hemolysis. New tubing avoids giving more of the incompatible blood still in the line, and saline supports blood pressure and urine flow to protect the kidneys from free hemoglobin.

Easy analogy or mental picture
Picture the wrong key forced into a lock: the red cells burst open, and the debris (hemoglobin) clogs the kidneys, darkening the urine.

Memory hook
Fever + back pain + dark urine in the first minutes = hemolysis: stop, save, saline, new line.

NCLEX decision rule
For any suspected transfusion reaction, stop the product first; then use the accompanying signs to name the type and choose what to monitor.

Why the other choices are wrong
A febrile nonhemolytic reaction causes fever and chills without hypotension or hemoglobinuria, so acetaminophen and resuming the unit are unsafe here. Anaphylaxis would bring hives, wheezing, or angioedema, and it does not cause fever or dark urine, so epinephrine and urticaria checks do not fit. Circulatory overload causes hypertension, crackles, and distended neck veins, so BNP is not the right marker. Slowing the rate continues exposure to incompatible blood. Temperature every 4 hours is too infrequent and nonspecific.