# Ten minutes after a red blood cell transfusion begins, a client develops chills and low back pain. For each finding or action, select the best classification.

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=395600&lang=en  
> language: en  
> subject: Complications of Procedures  
> category: ROR

## Question

Ten minutes after a red blood cell transfusion begins, a client develops chills and low back pain. For each finding or action, select the best classification.

|  | Reaction cue | Appropriate immediate action | Unsafe or delays evaluation |
| --- | --- | --- | --- |
| Chills and low back pain beginning 10 minutes after the transfusion starts |  |  |  |
| Stop the transfusion, assess airway, breathing, circulation, and vital signs, and activate help |  |  |  |
| Maintain IV access with normal saline and new tubing according to protocol |  |  |  |
| Notify the transfusion service, recheck identities, and preserve or send the unit, set, and required samples per protocol |  |  |  |
| Restart the blood slowly when symptoms ease without receiving protocol-based authorization |  |  |  |
| Discard the blood bag and tubing before the reaction investigation |  |  |  |

## Explanation

Chills and low back pain shortly after transfusion begins are reaction cues. Stop the transfusion, assess ABCs and vital signs, maintain IV access with normal saline and new tubing per protocol, notify the provider and transfusion service, verify identities, and preserve required specimens and equipment.

## In-depth explanation

Quick answer
Recognize the acute reaction cue, stop the transfusion, assess and escalate, maintain IV access with normal saline and new tubing per protocol, and notify the transfusion service while preserving evidence for investigation.

Why this is correct
Chills and low back pain within minutes of starting red blood cells can signal a serious reaction. Continued exposure must end while the client is stabilized and the component, labels, tubing, and required samples are evaluated.

Easy analogy or mental picture
Close the source first, keep a clean rescue line open, then preserve the trail needed to determine what happened.

Memory hook
Stop, assess, saline with new tubing, notify, verify, preserve.

NCLEX decision rule
For a suspected transfusion reaction, stop the blood before doing investigative steps. Follow the facility and transfusion-service protocol for IV fluid, identity checks, samples, and disposition of the unit and set.

Why the other choices are wrong
Restarting without authorization can re-expose the client. Discarding the bag and tubing removes materials needed for reaction investigation.

Source
1AABB Circular of Information for Blood and Blood Components
22026 NCLEX-RN Test Plan

## Clinical scenario

The nurse suspects an acute transfusion reaction and follows the facility's transfusion-reaction protocol. Emergency assessment and preservation of the blood component and administration set support both client safety and the investigation.

## Key concepts

- **Acute transfusion reaction** — An adverse clinical event occurring during or soon after blood-component administration that requires prompt assessment and investigation.
- **Transfusion service** — The laboratory service that selects and issues blood components and coordinates transfusion-reaction investigation.
- **Postreaction specimen** — A patient blood sample collected after a suspected reaction according to protocol for laboratory evaluation.

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