# Fifteen minutes after packed red blood cells are started, a client develops fever, chills, hypotension, back pain, dread, and pink urine. Which initial actions are correct? Select all that apply.

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=368319&lang=en  
> language: en  
> subject: System-Specific Assessments  
> category: ROR

## Question

Fifteen minutes after packed red blood cells are started, a client develops fever, chills, hypotension, back pain, dread, and pink urine. Which initial actions are correct? Select all that apply.

1

Notify the provider and transfusion service, send the remaining component and administration set for investigation, and obtain post-reaction blood and urine samples per protocol

2

Reduce the transfusion rate and monitor every 30 minutes because mild postoperative reactions often resolve while the same blood component continues

3

Give an antipyretic and medication for rigors, then restart the same blood component slowly after the client's discomfort improves

4

Classify the fever and chills as an uncomplicated febrile nonhemolytic reaction, attribute the back pain and pink urine to postoperative causes, and maintain the infusion while watching for hives or itching

5

Stop the transfusion immediately, disconnect the blood administration tubing, and maintain the existing vascular access with new tubing and 0.9% sodium chloride per protocol

6

Suspect an acute hemolytic transfusion reaction and prioritize support of blood pressure, urine output, renal perfusion, and treatment of coagulopathy if present

## Explanation

Fever, chills, hypotension, back pain, dread, and hemoglobinuria soon after transfusion strongly suggest an acute hemolytic transfusion reaction (Choice 6). Stop the transfusion immediately. Disconnect the blood administration set and maintain the existing vascular access with new tubing and 0.9% sodium chloride according to facility protocol (Choice 5). Notify the provider and transfusion service, send the implicated component and administration set, and obtain required post-reaction samples (Choice 1). Do not slow, restart, or continue the implicated unit while treating symptoms (Choices 2 and 3). This severe systemic presentation is not managed as an uncomplicated febrile or allergic reaction (Choice 4).

## In-depth explanation

Transfusion Reactions — Differentiation
Acute hemolytic (ABO incompatibility)
- Onset: minutes
- Fever, chills, back/flank pain, dread, hypotension, tachycardia, hemoglobinuria, possible DIC
- Action: STOP, disconnect at catheter hub, NEW saline + tubing, notify provider + blood bank, return unit, post-reaction labs

Febrile non-hemolytic (FNHTR)
- Onset: 30-60 min
- Temperature rise ≥1°C, chills, headache; no hypotension
- Action: STOP, antipyretic, leukoreduced products in future

Mild allergic
- Onset: minutes
- Urticaria, pruritus only; vitals stable
- Action: pause/slow, antihistamine, may resume cautiously per facility/order

Anaphylactic
- Onset: minutes
- Hypotension, bronchospasm, angioedema, shock
- Action: STOP, IM epinephrine, support airway, fluids

TRALI (transfusion-related acute lung injury)
- Onset: within 6 hr
- Acute respiratory distress, bilateral pulmonary edema, hypoxia
- Action: STOP, support oxygenation/ventilation, notify

TACO (transfusion-associated circulatory overload)
- Onset: during/within 6 hr
- Dyspnea, JVD, crackles, hypertension
- Action: STOP/slow, diuretic, upright, oxygen

Universal First Steps for Any Reaction
1. STOP transfusion
2. Disconnect at catheter hub — do not flush residual blood
3. NEW 0.9% NS line + tubing to maintain access
4. Stay with client; ABCs; vitals
5. Notify provider + blood bank
6. Return unit + tubing; collect post-reaction labs/urine per policy
7. Document

Memory Tip
"STOP-Disconnect-NEW saline-Notify-Return"

## Clinical scenario

Scenario
Adult post-op on PRBC, 15 min into transfusion: back pain, chills, dread, T 39, HR 124, BP 88/54, SpO2 92%, pink urine.

Recognition
Constellation = acute hemolytic transfusion reaction (likely ABO mismatch).

Initial Actions
1. STOP the transfusion
2. Disconnect at catheter hub + new 0.9% NS line + new tubing
3. Stay with client; ABCs; continuous vitals
4. Notify provider + blood bank
5. Return unit + tubing; collect post-reaction blood + urine samples
6. Hemodynamic + renal support per orders

Avoid
- Slowing and continuing the same unit
- Treating as "mild allergic" with diphenhydramine alone
- Reusing the existing blood tubing (residual blood)

## Key concepts

- **Acute Hemolytic Transfusion Reaction** — Severe, immediate (within minutes) reaction usually due to ABO incompatibility from clerical or identification errors. Recipient antibodies destroy donor red blood cells, causing intravascular hemolysis. Classic features: fever, chills, back/flank pain, sense of dread, hypotension, tachycardia, dyspnea, hemoglobinuria, and risk of DIC and acute kidney injury. Mortality is high without immediate action. Prevention: rigorous two-RN identification at the bedside before initiating transfusion.
- **Universal First Steps for a Suspected Reaction** — STOP the transfusion. Disconnect the blood tubing AT the catheter hub (do not flush residual blood through). Start a NEW 0.9% normal saline line with NEW tubing to maintain venous access. Stay with the client; assess ABCs and full vital signs. Notify the provider AND the blood bank. Return the unit and tubing to the blood bank for investigation. Collect post-reaction blood and urine samples per facility protocol. Document the reaction. Treat shock, fever, allergic, or respiratory features as indicated.
- **Differentiating Transfusion Reactions** — Acute hemolytic: minutes; fever, chills, back pain, hemoglobinuria, hypotension; ABO incompatibility. Febrile non-hemolytic (FNHTR): 30-60 min; isolated fever ≥1°C, chills, headache, vitals stable. Mild allergic: minutes; urticaria/pruritus only. Anaphylactic: minutes; hypotension, bronchospasm, angioedema. TRALI: within 6 hr; acute respiratory distress, bilateral pulmonary edema. TACO: during/within 6 hr; dyspnea, JVD, crackles, hypertension. Universal first steps apply to all; specific treatment differs.

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