A nurse is administering a packed red blood cell transfusion to a client. Fifteen minutes after starting the transfusion, the client reports chills, lower back pain, and a feeling of warmth. The client's temperature is 102°F (38.9°C), heart rate 120 beats/min, and blood pressure 90/60 mm Hg. Which actions should the nurse take? For each group, select all responses that apply.

Signs of an acute hemolytic transfusion reaction include fever, chills, back pain, and hypotension. The transfusion must be stopped immediately to prevent further hemolysis. The IV line should be maintained with normal saline using new tubing to avoid infusing more blood. Slowing the rate or continuing with antipyretics is dangerous. The provider and blood bank must be notified. The blood bag and tubing are sent to the blood bank for investigation. A urine specimen should be collected to check for hemoglobinuria, not only if oliguria develops. Documentation should occur as soon as possible after stabilizing the client.

Use the client-specific assessment findings and timing in the scenario rather than a memorized diagnosis label.

Connect the relevant cues to the safest nursing interpretation and action for this exact care setting.

The distractors are plausible in another context but are unsupported, mistimed, lower priority, or incomplete for the findings presented.

Address immediate threats first, stay within nursing scope, and reassess the client after the selected intervention.

For acute transfusion reaction, select responses that are both clinically supported and appropriate at this point in care.

• hemolytic transfusion reaction — A severe reaction caused by ABO incompatibility, leading to destruction of donor red blood cells and potentially fatal complications.
• normal saline — An isotonic solution used to maintain IV access and support blood pressure during a transfusion reaction.
• blood bank — The laboratory responsible for blood product compatibility testing and investigation of transfusion reactions.