# Fifteen minutes after a packed red blood cell transfusion begins, a client reports chills, back pain, and shortness of breath. Which action has priority?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=393561&lang=en  
> language: en  
> subject: Complications of Procedures  
> category: ROR

## Question

Fifteen minutes after a packed red blood cell transfusion begins, a client reports chills, back pain, and shortness of breath. Which action has priority?

## Option

1. Slow the transfusion and reassess in 15 minutes.
2. Administer acetaminophen and continue the transfusion.
3. Collect a urine specimen before changing the infusion.
4. Stop the transfusion and maintain IV access with 0.9% sodium chloride using new tubing. **✔ Correct answer**

**Correct answer: 4**

## Explanation

Chills, back pain, and shortness of breath soon after transfusion begins suggest an acute transfusion reaction. The nurse should stop the transfusion immediately and maintain IV access with normal saline using new tubing, then notify the provider and blood bank according to policy.

## In-depth explanation

Clinical Judgment
When a transfusion reaction is suspected, prevent more blood from entering the client before collecting secondary data.

Memory Tip
STOP blood, keep vein open with saline, notify, send blood and tubing per policy.

KR vs US
NCLEX prioritizes immediate interruption of the blood product and a new saline line for safety.

## Clinical scenario

Clinical Practice Guide
Open RN blood product guidance states that signs of transfusion reaction require stopping the transfusion and starting normal saline with new primed tubing according to policy.

Caution
Do not flush through the existing blood tubing because remaining blood could enter the client.

## Key concepts

- **Transfusion Reaction** — An adverse response during or after blood product administration that can include fever, chills, back pain, dyspnea, hypotension, or hives.
- **Normal Saline** — 0.9% sodium chloride, the standard compatible IV fluid used with blood products.
- **Blood Bank** — The transfusion service that supports reaction workup, product tracking, and compatibility investigation.

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