# 20 minutes into a packed red blood cell transfusion, a client has chills and a temperature of 38.3 C, up from 37.0 C. The blood pressure is unchanged, and the client reports no back pain. Which action should the nurse take first?

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> subject: Unexpected Response to Therapies  
> category: PA

## Question

20 minutes into a packed red blood cell transfusion, a client has chills and a temperature of 38.3 C, up from 37.0 C. The blood pressure is unchanged, and the client reports no back pain. Which action should the nurse take first?

## Option

1. Collect a urine sample to look for hemoglobinuria before other steps
2. Stop the transfusion and keep the line open with 0.9% sodium chloride **✔ Correct answer**
3. Give the prescribed acetaminophen and continue the unit that is running
4. Return the unit to the blood bank and begin the next unit that is ready

**Correct answer: 2**

## Explanation

Any new fever during transfusion is treated as a possible reaction. Stopping the transfusion while keeping venous access open limits exposure and preserves the route for treatment.

## In-depth explanation

Quick answer
Stop the transfusion and maintain the intravenous line with saline.

Why this is correct
A febrile response can be benign or the first sign of a hemolytic reaction, and they cannot be separated at the bedside in the first minutes. Stopping limits how much incompatible blood is given while the saline keeps a route available for treatment.

Easy analogy or mental picture
Stopping the infusion is like closing a valve before inspecting the pipe. The image conveys containment and does not mean the intravenous access is removed.

Memory hook
New fever during blood: stop the unit, keep the line.

NCLEX decision rule
For any suspected transfusion reaction, stop the blood, keep the line open with saline, then assess and notify. Investigation and treatment follow that sequence rather than replace it.

Why the other choices are wrong
Urine testing, antipyretics, and returning the bag are all part of transfusion reaction management, but each assumes the unit is already stopped.References

- [1]NCSBN: 2026 NCLEX-RN Test PlanNational Council of State Boards of Nursing

- [2]MedlinePlus: Blood Transfusion and DonationU.S. National Library of Medicine

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