# A nurse is transfusing packed red blood cells (pRBCs) to a 68-year-old patient on post-operative day 1. Twenty minutes into the transfusion, the patient reports sudden severe low back pain and rigors. Assessment reveals temperature 39.5°C (baseline 37.0°C), BP 78/52 mmHg, and dark reddish-brown urine in the indwelling catheter bag. The nurse recognizes signs of an acute hemolytic transfusion reaction (AHTR). Which actions should the nurse take? Select all that apply.

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=372669&lang=en  
> language: en  
> subject: System-Specific Assessments  
> category: ROR

## Question

A nurse is transfusing packed red blood cells (pRBCs) to a 68-year-old patient on post-operative day 1. Twenty minutes into the transfusion, the patient reports sudden severe low back pain and rigors. Assessment reveals temperature 39.5°C (baseline 37.0°C), BP 78/52 mmHg, and dark reddish-brown urine in the indwelling catheter bag. The nurse recognizes signs of an acute hemolytic transfusion reaction (AHTR). Which actions should the nurse take? Select all that apply.

1

Insert or confirm indwelling urinary catheter patency, monitor hourly urine output targeting at least 1 mL/kg/hour, and administer IV fluids as ordered to prevent acute tubular necrosis.

2

Notify the blood bank immediately, return the blood bag and all transfusion tubing intact, and send blood and urine specimens for the AHTR workup.

3

Stop the transfusion immediately and disconnect the blood administration tubing from the IV access site.

4

Slow the infusion rate to 10 mL/hour and monitor closely, as the reaction may self-resolve with continued transfusion.

5

Administer acetaminophen 650 mg orally and diphenhydramine 25 mg IV to control the fever and chills while monitoring the patient.

6

Maintain IV access and begin infusing 0.9% normal saline through new IV tubing to support blood pressure and protect renal perfusion.

## Explanation

For suspected acute hemolytic transfusion reaction, stop the transfusion immediately and disconnect the blood tubing (Choice 3). Notify the blood bank, return the bag and tubing, and send the required blood and urine specimens (Choice 2). Maintain IV access with new tubing and 0.9% saline to support perfusion (Choice 6). Confirm urinary-catheter patency, monitor urine output closely, and administer ordered fluids to reduce acute kidney injury from hemoglobinuria (Choice 1). Never slow and continue incompatible blood (Choice 4). Acetaminophen and diphenhydramine do not treat intravascular hemolysis and must not delay the emergency response (Choice 5).

## In-depth explanation

Clinical Judgment
AHTR is a life-threatening emergency caused by ABO incompatibility — usually a clerical/labeling error. Complement activation causes massive intravascular hemolysis → free hemoglobin → renal tubular toxicity → DIC. The two dangerous distractors mirror common NCLEX traps:
② "slow the rate" — correct for FNHTR (febrile non-hemolytic); NEVER for AHTR — STOP immediately
⑤ "acetaminophen + diphenhydramine" — correct for FNHTR/allergic; NEVER for AHTR — masks life-threatening progression

Memory Tip
AHTR STOP sequence: Stop blood → NS via NEW tubing → Notify MD + Blood Bank → Return bag + tubing + samples → Hourly UO ≥1 mL/kg/h → Document/Incident report
AHTR clues: ABO mismatch → fever + rigors + FLANK PAIN + dark urine + hypotension = STOP NOW
Reaction comparison: FNHTR = fever only (slow/stop + antipyretics ok) | Allergic mild = urticaria (stop + antihistamine) | AHTR = fever+pain+dark urine+shock = STOP + emergency

KR vs US
In Korea, blood bank notification protocols and incident reporting for transfusion reactions may differ. In the US, TJC requires reporting all serious adverse transfusion events. NCLEX expects the full AHTR response sequence including blood bank specimen return.

## Clinical scenario

Clinical Practice Guide
AHTR Management Sequence (AABB/TJC):
(1) Stop transfusion IMMEDIATELY — disconnect blood tubing from IV site
(2) Maintain IV access — new NS tubing, do NOT flush blood into patient
(3) Notify physician and charge nurse STAT
(4) Notify blood bank — return blood bag, all tubing, IV fluid bag intact with labels
(5) Draw blood samples (repeat type and screen, DAT/Coombs, CBC, BMP, LFTs, PT/INR, fibrinogen — screen for DIC)
(6) Catheterize if not done; monitor hourly UO — IV fluids to maintain ≥1 mL/kg/h; avoid nephrotoxins
(7) Complete transfusion reaction report and incident documentation

Transfusion Reaction Differentiation:
FNHTR — fever ±1°C above baseline, no hemolysis; slow/stop + acetaminophen; can often restart new unit
Mild allergic — urticaria only, no systemic signs; stop + diphenhydramine; may restart if symptoms resolve
AHTR — fever + rigors + flank/back pain + dark urine + hemolysis + hypotension/shock; STOP + emergency protocol
Anaphylaxis — urticaria + bronchospasm + hypotension + no fever; STOP + epinephrine 0.3 mg IM

## Key concepts

- **AHTR (Acute Hemolytic Transfusion Reaction) / 급성 용혈성 수혈 반응** — AHTR definition: A life-threatening transfusion complication caused by ABO blood group incompatibility, almost always from clerical error (wrong patient, wrong unit). IgM antibodies activate complement → massive intravascular hemolysis → free hemoglobin nephrotoxicity → ATN, DIC, shock. Mortality up to 10% once established.
- **DAT / Direct Antiglobulin Test (Coombs Test) / 직접 항글로불린 검사** — DAT (Direct Antiglobulin Test/Coombs): Detects antibodies or complement bound to red blood cells. Positive DAT after transfusion reaction confirms sensitization. Part of AHTR workup along with plasma-free hemoglobin, bilirubin, haptoglobin (decreased), urine hemoglobin.
- **ATN (Acute Tubular Necrosis) / 급성 세뇨관 괴사 — AHTR 신장 합병증** — ATN in AHTR: Free hemoglobin from lysed RBCs precipitates in renal tubules, causing direct tubular toxicity and tubular obstruction. IV fluid resuscitation targeting urine output ≥1 mL/kg/hour dilutes free hemoglobin and maintains tubular flow. Avoid NSAIDs, aminoglycosides, and contrast agents — all nephrotoxic.

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