# The nurse reviews the record during a red blood cell transfusion. Which findings require immediate follow-up for a possible acute hemolytic transfusion reaction? Highlight the new reaction findings. > source: MyMerci (mymerci.kr) > url: https://mymerci.kr/pages/nclex_q.php?qn_id=494430&lang=en > language: en > subject: Complications of Procedures > category: ROR ## Question The nurse reviews the record during a red blood cell transfusion. Which findings require immediate follow-up for a possible acute hemolytic transfusion reaction? Highlight the new reaction findings. Nurses' Notes 1300: The nurse verifies the prescription, consent, and compatibility report before transfusion. The record confirms that two identifiers match the blood product label and compatibility tag. Baseline temperature is 36.9 °C, blood pressure is 128/74 mm Hg, and oxygen saturation is 97%. The client reports chronic bilateral knee discomfort rated 2/10. At 1315, the peripheral IV remains patent without redness or swelling. The red blood cell transfusion begins slowly. At 1330, the client develops a temperature of 38.4 °C with shaking rigors. The client then reports new aching pain across the lower back and left flank. The nurse notes that chronic knee discomfort remains unchanged at 2/10. At 1335, blood pressure decreases to 82/48 mm Hg from the baseline value. Oxygen saturation remains 96% on room air. The nurse confirms that the oxygen saturation is unchanged from the pretransfusion reading. At 1340, the client voids a small amount of newly dark red-brown urine. The client states that breathing felt comfortable when the transfusion began. The blood tubing remains connected while the nurse stays with the client. ## Explanation Follow up on fever with rigors, new flank pain, hypotension, and dark urine during the transfusion. These new findings can accompany acute hemolysis and require the transfusion to be stopped and evaluated immediately. ## In-depth explanation Quick answer The new fever with rigors, flank pain, hypotension, and dark urine are the reaction cues. Stop the transfusion, maintain venous access with the appropriate solution per protocol, assess the client, and notify the required team members. Why this is correct An acute hemolytic transfusion reaction can begin during or soon after transfusion with fever, chills, back or flank pain, hypotension, hemoglobinuria, oliguria, and other signs of hemolysis. Continuing exposure can worsen shock, kidney injury, and coagulation problems, so recognition and stopping the blood product come first.[2] Easy analogy or mental picture Think of the transfused cells as a delivery that the immune system suddenly identifies as dangerous. Fever and pain are the alarm, while falling pressure and dark urine show downstream harm. The analogy does not identify the exact reaction type without the formal transfusion workup. Memory hook New heat, pain, pressure drop, dark urine: stop the blood and investigate. NCLEX decision rule During any transfusion, compare every new symptom with the pretransfusion baseline. If a potentially serious reaction appears, stop the transfusion before completing phone calls or collecting confirmatory tests; then follow the facility reaction protocol. Why the other choices are wrong Verified identifiers, an intact IV, unchanged chronic knee pain, stable baseline oxygen saturation, and a comfortable start do not represent new reaction findings. They help establish that the selected changes occurred after the transfusion began.References - [1]NCSBN: 2026 NCLEX-RN Test PlanNational Council of State Boards of Nursing - [2]CDC NHSN: Acute Hemolytic Transfusion Reaction DefinitionCenters for Disease Control and Prevention ## Related questions - [A nurse cares for a client 12 hours after thoracotomy with a chest tube connected to a wet…](https://mymerci.kr/pages/nclex_q.php?qn_id=366310&lang=en) - [A nurse is caring for a 64-year-old client 2 hours after a diagnostic cardiac catheterizat…](https://mymerci.kr/pages/nclex_q.php?qn_id=368186&lang=en) - [A patient on mechanical ventilation has bilateral infiltrates on chest x-ray, no signs of …](https://mymerci.kr/pages/nclex_q.php?qn_id=372717&lang=en) - [A 38-week newborn is delivered limp, apneic, and cyanotic. 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