# Fifteen minutes after a packed red blood cell transfusion begins, a client reports chills and back pain. The temperature rises from 37.1 C to 38.4 C. What should the nurse do first?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=394124&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 and back pain. The temperature rises from 37.1 C to 38.4 C. What should the nurse do first?

## Option

1. Slow the transfusion and recheck the temperature in 1 hour.
2. Give acetaminophen and continue the transfusion.
3. Stop the transfusion and maintain IV access with normal saline using new tubing. **✔ Correct answer**
4. Document the findings as expected during the first 15 minutes.

**Correct answer: 3**

## Explanation

Fever, chills, and back pain shortly after transfusion begins suggest a transfusion reaction. The nurse should stop the transfusion immediately, keep IV access open with normal saline using new tubing, and follow reaction protocol. Continuing the blood can worsen the reaction.

## In-depth explanation

Clinical Judgment
Suspected transfusion reaction means stop the blood first.

Memory Tip
Stop blood, keep vein open.

## Clinical scenario

Clinical Practice Guide
Transfusion monitoring is especially important during the first minutes and includes temperature, chills, pain, dyspnea, and vital signs.

Caution
Do not restart blood until the reaction is evaluated according to protocol.

## Key concepts

- **Transfusion Reaction** — An adverse response to blood product administration.
- **Packed Red Blood Cells** — A blood component used to increase oxygen-carrying capacity.
- **Normal Saline** — The compatible IV fluid used to maintain access during transfusion reaction management.

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