# A nurse is administering a unit of packed red blood cells to a client. Twenty minutes after the start of the transfusion the client develops a temperature of 38.9 C, chills, hypotension, and flank pain. Which actions should the nurse take immediately? Select all that apply. > source: MyMerci (mymerci.kr) > url: https://mymerci.kr/pages/nclex_q.php?qn_id=364947&lang=en > language: en > subject: System-Specific Assessments > category: ROR ## Question A nurse is administering a unit of packed red blood cells to a client. Twenty minutes after the start of the transfusion the client develops a temperature of 38.9 C, chills, hypotension, and flank pain. Which actions should the nurse take immediately? Select all that apply. 1 Notify the provider and the blood bank, and prepare to send the unit and tubing for analysis 2 Stop the transfusion and disconnect the blood tubing from the client 3 Continue the transfusion at half the rate while monitoring vital signs 4 Maintain a patent IV by attaching new tubing primed with normal saline 5 Administer acetaminophen and continue the infusion to manage the febrile response ## Explanation Acute hemolytic transfusion reaction is a medical emergency. Stopping the transfusion is the first action. Disconnect the blood-product tubing entirely so no additional incompatible blood enters the client; new tubing primed with normal saline maintains IV access for fluid resuscitation. Notify the provider and blood bank, and return the unit and tubing for laboratory analysis. Continuing or slowing the transfusion or treating only the fever delays critical care and worsens hemolysis. ## In-depth explanation Clinical Judgment Acute hemolytic transfusion reaction signs: fever, chills, hypotension, flank pain (kidney capsule), dark urine (hemoglobinuria), DIC. First action: STOP the transfusion immediately. Disconnect blood tubing — never just slow it. Maintain IV with new normal saline tubing for fluid resuscitation. Memory Tip Reaction = STOP, change tubing to NS, notify, send back unit + tubing KR vs U AABB Technical Manual and Korean Society of Blood Transfusion both follow the same emergency response. Mandatory clerical bedside check by two nurses before transfusion remains the most effective prevention. Korean tertiary blood banks use identical reporting and lookback procedures. ## Clinical scenario Clinical Practice Guide Acute transfusion reactions: - Acute hemolytic: ABO mismatch, fever, hypotension, flank pain, dark urine — STOP, IV NS, supportive care, treat DIC - Febrile non-hemolytic (FNHTR): fever and chills only — STOP, evaluate, give antipyretic; resume only if hemolysis ruled out - Allergic / urticaria: hives, itching — STOP, antihistamine, may resume if mild and resolved - Anaphylactic: airway swelling, severe hypotension, IgA deficiency — STOP, epinephrine, ICU - TRALI: ARDS within 6 hours — STOP, supportive ventilation - TACO: volume overload — STOP, diuretic, oxygen, upright Standard prevention: - Two-RN bedside ID check with the unit, ABO, Rh, expiration - Vital signs at baseline, 15 min, q30 min, completion - Stay with the client for the first 15 minutes — most reactions occur early - Use blood-compatible tubing and 0.9% normal saline only Caution Send the unit, tubing, and a fresh blood sample to the blood bank along with a urine sample for free hemoglobin. Document times, vital signs, interventions verbatim. ## Key concepts - **Acute hemolytic transfusion reaction** — Most severe transfusion reaction, usually due to ABO mismatch. Antibody-mediated hemolysis with fever, hypotension, flank pain (kidney), dark urine, and DIC. Stop transfusion, normal saline, and supportive care. Mortality up to 25 percent if not treated rapidly. - **Two-RN bedside check** — Standard pre-transfusion safety practice. Two licensed nurses verify client identity (two identifiers), unit ABO/Rh, expiration, and order against the unit at the bedside. Most effective single intervention to prevent ABO-mismatch reactions. - **Tubing change protocol** — After stopping a transfusion for a reaction, do not simply pause the line. Disconnect the blood-product tubing and attach new tubing primed with 0.9% normal saline to the client IV. 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