# A nurse is caring for a patient who received a blood transfusion 2 hours ago. Which assessment finding would be the most important indicator of a potential transfusion reaction? > source: MyMerci (mymerci.kr) > url: https://mymerci.kr/pages/nclex_q.php?qn_id=542702 > language: ko > subject: Fundamentals ## 문제 A nurse is caring for a patient who received a blood transfusion 2 hours ago. Which assessment finding would be the most important indicator of a potential transfusion reaction? ## 보기 1. Temperature increase from 98.6°F to 101.2°F with chills **✔ 정답** 2. Blood pressure decrease from 120/80 to 110/70 mmHg 3. Heart rate increase from 78 to 88 beats per minute 4. Oxygen saturation decrease from 98% to 96% **정답: 1** ## 해설 Temperature elevation with chills is a classic sign of a febrile transfusion reaction, requiring immediate intervention like stopping the transfusion. Other findings like mild BP or HR changes are less specific and may not indicate an urgent reaction. ## 심화 해설 Understanding the Clinical Scenario The patient is 2 hours post-blood transfusion. This timing places the patient squarely within the window for an acute transfusion reaction (ATR), which is defined as any unfavorable response occurring during or within 24 hours of blood component administration [2]. The nurse's priority is to identify the most critical indicator of a potential reaction, distinguishing it from less specific or less urgent clinical changes. Analysis of Assessment Findings The core of this question lies in recognizing the classic and most common presentation of a potentially serious acute reaction versus expected or nonspecific variations. * Option 1: Temperature increase from 98.6°F to 101.2°F with chills This finding is the hallmark of a febrile non-hemolytic transfusion reaction (FNHTR) and can also be an early sign of a more severe acute hemolytic transfusion reaction. The literature identifies fever and chills as primary presenting symptoms of acute transfusion reactions [1]. A temperature spike of this magnitude, especially when accompanied by chills, is a highly specific and concerning indicator that demands immediate cessation of the transfusion and further evaluation. In studies of pediatric transfusion reactions, febrile reactions are consistently among the most frequently reported types . * Option 2: Blood pressure decrease from 120/80 to 110/70 mmHg A slight drop in systolic blood pressure by 10 mmHg is a relatively minor change. While hypotension can be a feature of severe reactions like anaphylaxis or sepsis, this isolated, modest decrease lacks the specificity and severity to be the most important indicator when compared to a significant fever with chills. * Option 3: Heart rate increase from 78 to 88 beats per minute A mild sinus tachycardia of an increase of 10 beats per minute is a very nonspecific finding. It could be related to anxiety, mild volume shifts, or a reaction. In the context of a transfusion, it warrants monitoring but is not the most definitive or urgent sign of a reaction when compared to a febrile response. * Option 4: Oxygen saturation decrease from 98% to 96% A drop in oxygen saturation by 2% is a subtle change that can occur with patient movement or transient fluid shifts. While a more dramatic desaturation would be a critical sign of transfusion-associated circulatory overload (TACO) or transfusion-related acute lung injury (TRALI), this minor decrease is not the most immediate or specific indicator of a reaction in this early phase [1]. The Priority Nursing Judgment The most important indicator is the significant temperature elevation with chills. The classification of transfusion reactions begins with the timing of onset, and the acute period is where vigilant monitoring for symptoms like fever is critical [1]. A rise in temperature is a sentinel sign that triggers the immediate nursing action protocol: stop the transfusion, maintain the IV line with normal saline, monitor vital signs, and notify the provider. The other options represent changes that are either too subtle, nonspecific, or not the classic, most frequent initial indicator of a potentially life-threatening acute hemolytic reaction or a common FNHTR [2].References (research sources) - [1]Noninfectious Complications of Blood TransfusionResearch articleKhan AI, Goldin J, Gupta G. (2026) - [2]Frequency of Acute Adverse Transfusion Reactions at King Saud Medical City, Riyadh, Saudi Arabia.Research articleAboshaya IM, Sajid MR, Saleem RA, Aldosari S, Siraj H. (2026) · DOI: 10.3390/jcm15124432 ## 임상 시나리오 Clinical Practice Guide: Post-Transfusion Assessment When monitoring a patient 2 hours post-transfusion, the nurse must prioritize assessment findings that indicate an acute transfusion reaction (ATR). The most critical indicator is a new onset of fever (temperature increase ≥1°C or ≥2°F from baseline) accompanied by chills or rigors. This presentation is the hallmark of a febrile non-hemolytic transfusion reaction (FNHTR) and can also be the earliest sign of a life-threatening acute hemolytic reaction or bacterial contamination. Immediate Nursing Actions - **Stop the Transfusion Immediately:** Disconnect the blood tubing from the intravenous access. Do not flush the line with the remaining blood product. - **Maintain IV Access:** Keep the vein open with a new infusion of 0.9% normal saline using new tubing to maintain hemodynamic stability and allow for emergency medication administration. - **Monitor Vital Signs Closely:** Assess temperature, blood pressure, heart rate, respiratory rate, and oxygen saturation every 5-15 minutes. Watch for signs of deterioration such as hypotension, tachycardia, dyspnea, or flank pain which may indicate a severe hemolytic reaction. - **Verify Patient and Product Identification:** Recheck the patient's identification band, blood unit number, and compatibility tags at the bedside to rule out a clerical error leading to an ABO incompatibility. - **Notify the Provider and Blood Bank:** Report the reaction immediately. Prepare to collect blood and urine samples as ordered for direct antiglobulin test (DAT), serum haptoglobin, plasma-free hemoglobin, and urinalysis. - **Document Thoroughly:** Record the time of onset, specific symptoms, vital sign trends, volume of blood infused, and all interventions performed in the medical record. Mild, isolated changes such as a slight decrease in blood pressure (e.g., 120/80 to 110/70 mmHg), a minor increase in heart rate (e.g., 78 to 88 bpm), or a small dip in oxygen saturation (e.g., 98% to 96%) are nonspecific and can be attributed to volume shifts, anxiety, or sensor artifact. While these should be monitored, they do not warrant immediate cessation of the transfusion in the absence of a febrile response or other cardinal signs like urticaria, respiratory distress, or pain. ## 핵심 개념 - **Febrile Non-Hemolytic Transfusion Reaction (FNHTR)** — A common acute transfusion reaction defined by a temperature increase of ≥1°C or ≥2°F from baseline, often accompanied by chills, rigors, and discomfort, caused by recipient antibodies reacting to donor leukocytes or cytokines in the blood product. - **Acute Hemolytic Transfusion Reaction** — A severe, life-threatening reaction caused by ABO incompatibility where recipient antibodies rapidly destroy donor red blood cells, presenting with fever, chills, flank pain, hemoglobinuria, hypotension, and disseminated intravascular coagulation. - **Acute Transfusion Reaction (ATR)** — Any adverse event related to blood component administration occurring during or within 24 hours of the transfusion, requiring immediate nursing intervention including stopping the infusion and assessing vital signs. ## 같은 주제 문제 - [A nurse is preparing to administer a unit of packed red blood cells to a patient. 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