# Place the nursing actions in order after a client develops fever, rigors, dyspnea, and back pain 10 minutes after a packed red blood cell transfusion begins.

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=394877&lang=en  
> language: en  
> subject: Complications of Procedures  
> category: ROR

## Question

Place the nursing actions in order after a client develops fever, rigors, dyspnea, and back pain 10 minutes after a packed red blood cell transfusion begins.

Notify the responsible clinician and blood bank promptly and obtain the prescribed reaction workup and treatment orders

Assess airway, breathing, circulation, vital signs, oxygen saturation, lung sounds, pain, and urine appearance

Recheck client and product identifiers and send the blood bag, tubing, and ordered blood or urine specimens according to policy

Stop the transfusion immediately, disconnect the blood tubing, and remain with the client

Maintain venous access with 0.9% sodium chloride through new tubing without flushing blood into the client

## Explanation

Stop the blood product first and prevent additional exposure. Preserve venous access with compatible saline and new tubing, then establish the severity of the reaction through focused assessment while help is mobilized. Notify the clinician and blood bank for treatment and investigation. Complete required identity checks, specimens, and return of the bag and tubing without discarding evidence.

## In-depth explanation

Correct sequence
Stop blood → keep the vein open with new saline tubing → assess severity → notify and treat → preserve and submit reaction evidence.

Why this is correct
Continuing the transfusion can worsen hemolysis, respiratory compromise, or sepsis. The blood bag and tubing must remain available for investigation, and a suspected contaminated unit requires immediate cessation and testing.

NCLEX decision rule
Remove the cause first, maintain access safely, assess the client, then complete the diagnostic and reporting pathway.References
1CDC: blood component contamination and reaction guidance
2NCSBN 2026 NCLEX-RN Test Plan

## Clinical scenario

Suspected acute transfusion reaction
The client is awake and the blood product is still infusing. Follow the facility's transfusion-reaction protocol; laboratory specimens and product-return requirements may vary.

## Key concepts

- **Acute Transfusion Reaction** — A new adverse clinical response occurring during or shortly after blood-component administration.
- **Hemolysis** — Destruction of red blood cells that can cause fever, pain, hypotension, hemoglobinuria, and kidney injury.
- **Clerical Check** — A verification of the client, label, unit, and documentation used to investigate possible mismatch.

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_For study reference only. Always follow current clinical guidelines and your institution’s protocols._