# Fifteen minutes after a packed red blood cell transfusion begins, the client reports chills and back pain. The temperature rises from 37.0 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=396611&lang=en  
> language: en  
> subject: Complications of Procedures  
> category: ROR

## Question

Fifteen minutes after a packed red blood cell transfusion begins, the client reports chills and back pain. The temperature rises from 37.0 C to 38.4 C. What should the nurse do first?

## Option

1. Stop the transfusion and keep the IV line open with normal saline using new tubing. **✔ Correct answer**
2. Slow the transfusion and recheck the temperature in 1 hour.
3. Administer the next unit of blood to complete the prescription.
4. Document the symptoms as expected during transfusion.

**Correct answer: 1**

## Explanation

Fever, chills, and back pain shortly after transfusion begins suggest a transfusion reaction. The nurse should stop the transfusion and maintain IV access with normal saline using appropriate tubing while following protocol. Continuing the transfusion can worsen the reaction.

## In-depth explanation

Clinical Judgment
Use the client cues, timing, labs, and safety risks to select the response that best fits Acute transfusion reaction.

Memory Tip
Match the strongest cue cluster to the safest nursing judgment.

KR vs US
NCLEX items reward cue-based priority thinking rather than isolated recall.

## Clinical scenario

Clinical Practice Guide
For Acute transfusion reaction, compare the complete cue pattern with the client's current stability, ordered data, and expected nursing scope.

Caution
Do not choose an action from one isolated cue when the full scenario changes priority or safety.

## Key concepts

- **Transfusion Reaction** — An adverse response to a blood product.
- **Packed Red Blood Cells** — A blood product used to increase oxygen-carrying capacity.
- **Normal Saline** — An isotonic crystalloid compatible with many blood administration protocols.

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