# A 45-year-old female client with severe iron-deficiency anemia is receiving the first unit of packed red blood cells (PRBCs). Fifteen minutes after the infusion begins, the client reports chills, low back pain, and a feeling of impending doom. Vital signs change from baseline (T 36.8°C / HR 88 / BP 122/76 / SpO2 98%) to T 39.0°C / HR 122 / BP 96/58 / SpO2 90%. Which is the priority nursing action?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=361898&lang=en  
> language: en  
> subject: System-Specific Assessments  
> category: ROR

## Question

A 45-year-old female client with severe iron-deficiency anemia is receiving the first unit of packed red blood cells (PRBCs). Fifteen minutes after the infusion begins, the client reports chills, low back pain, and a feeling of impending doom. Vital signs change from baseline (T 36.8°C / HR 88 / BP 122/76 / SpO2 98%) to T 39.0°C / HR 122 / BP 96/58 / SpO2 90%. Which is the priority nursing action?

## Option

1. Stop the transfusion immediately, disconnect the blood tubing, maintain IV access with new normal saline tubing at a TKO rate, notify the provider and the blood bank, and send the remaining blood and a post-transfusion blood/urine sample for analysis. **✔ Correct answer**
2. Document the reaction in the client's chart, administer ordered antipyretics such as acetaminophen to reduce the fever, ensure the IV line is patent, and carefully monitor the client through the remainder of the blood transfusion.
3. Temporarily pause the transfusion and keep the IV line open with the current blood tubing, recheck vital signs in 10 minutes; if the fever and hypotension resolve, resume the transfusion at the original rate while continuing to assess.
4. Slow the transfusion rate to 50 mL per hour, administer acetaminophen 650 mg orally and diphenhydramine 25 mg IV as premedication, apply oxygen via nasal cannula, and continue to monitor vital signs closely for any worsening.

**Correct answer: 1**

## Explanation

This is an acute hemolytic transfusion reaction (AHTR) — fever ≥1°C above baseline, chills, low back pain, a feeling of impending doom, hypotension, and hypoxemia within minutes of starting the unit are classic features and reflect ABO incompatibility with rapid intravascular hemolysis. The priority is immediate cessation plus a 5-step response: STOP → DISCONNECT the blood tubing (do not just clamp) → MAINTAIN IV with NEW saline tubing at TKO → NOTIFY provider and blood bank → SAVE the unit and send blood/urine samples for analysis. Option 4 — slowing the rate or premedicating during an active reaction is unsafe. Option 3 — a brief pause and restart re-exposes the client to incompatible red cells. Option 2 — documenting and continuing the unit is dangerous and may lead to acute kidney injury, DIC, shock, or death.

## In-depth explanation

Clinical Judgment
Apply NCJMM: Recognize cues (T 36.8 → 39.0, chills, low back pain, impending doom, hypotension, hypoxemia within 15 minutes of starting) → Analyze cues (acute hemolytic transfusion reaction; ABO incompatibility most likely) → Generate solutions (5-step transfusion-reaction response) → Take action (STOP → DISCONNECT → new saline at TKO → notify provider and blood bank → save unit and samples) → Evaluate outcomes (no further hemolysis, renal protection, root-cause analysis to prevent recurrence).

Memory Tip
5-step S-D-N-N-S: Stop, Disconnect, New saline TKO, Notify, Save unit & samples. A simple clamp is not enough — the entire tubing must be swapped to a fresh saline set. Fever ≥1°C above baseline + back pain + chills is the classic triad of acute hemolysis.

KR vs US
In Korean practice, an isolated fever during transfusion is often handled by slowing the rate and observing. NCLEX requires immediate STOP for any suspected transfusion reaction. Slowing the rate, premedicating, or pausing-and-restarting are all wrong on NCLEX.

## Clinical scenario

Clinical Practice Guide
AABB and FDA acute transfusion-reaction guidance: any new fever ≥1°C above baseline, chills, dyspnea, hypotension, back/flank pain, hematuria, hives, or feeling of impending doom after starting a unit triggers immediate STOP. The 5-step response is universal across reaction types (AHTR, febrile non-hemolytic, allergic, anaphylactic, TRALI, TACO). Differential diagnosis follows after stopping.

Caution
The first 15 minutes require the nurse at the bedside with close monitoring. NCLEX often tests clamping the line only vs. changing the tubing to fresh saline — clamping leaves donor cells in the line; new saline tubing is the standard.

## Key concepts

- **Acute hemolytic transfusion reaction (AHTR)** — A life-threatening reaction (often ABO incompatibility) that occurs within minutes of starting an incompatible unit. Classic cues: fever ≥1°C above baseline, chills, low back/flank pain, dyspnea, hypotension, hemoglobinuria, and feeling of impending doom. Untreated, it progresses to acute kidney injury, DIC, shock, and death.
- **TKO (Keep-Vein-Open) rate** — A minimal IV infusion rate (typically 5–20 mL/hr) used to keep the catheter patent without delivering significant fluid volume. After stopping a transfusion, IV access is maintained at TKO so emergency medications and resuscitation remain immediately available.
- **5-step transfusion-reaction response** — The universal nursing response to any suspected transfusion reaction: (1) STOP the transfusion, (2) DISCONNECT the blood tubing entirely, (3) attach NEW normal saline tubing at TKO rate, (4) NOTIFY the provider and blood bank, and (5) SAVE the remaining blood and send post-reaction blood and urine specimens for analysis.

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