# Clinical context: A client was comfortable before a red-blood-cell transfusion. Twelve minutes after it began, the client reports sudden chills, severe low-back pain, and chest tightness. BP is 82/48 mm Hg, HR 128/min, RR 22/min, temperature 38.0°C (100.4°F), and SpO2 96% on room air. New dark-red urine appears in the catheter tubing. Lung sounds are clear, neck veins are flat, and there is no hives, wheezing, or facial swelling. The IV site is dry without swelling. Complete the diagram by selecting the condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=617383&lang=en  
> language: en  
> subject: Adverse Effects/Contraindications/Interactions  
> category: PPT

## Question

Clinical context: A client was comfortable before a red-blood-cell transfusion. Twelve minutes after it began, the client reports sudden chills, severe low-back pain, and chest tightness. BP is 82/48 mm Hg, HR 128/min, RR 22/min, temperature 38.0°C (100.4°F), and SpO2 96% on room air. New dark-red urine appears in the catheter tubing. Lung sounds are clear, neck veins are flat, and there is no hives, wheezing, or facial swelling. The IV site is dry without swelling.

Complete the diagram by selecting the condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.

Condition

Select 1
Acute hemolytic transfusion reaction
Transfusion-associated circulatory overload
Transfusion-related acute lung injury
Anaphylactic transfusion reaction

Actions to take

Select 2
Give prescribed IV furosemide
Give prescribed epinephrine 0.5 mg IM
Stop the transfusion immediately
Slow the rate and give prescribed acetaminophen
Infuse 0.9% saline through new tubing

Parameters to monitor

Select 2
Jugular venous distention
Hourly urine output
Skin for urticaria
Serum haptoglobin level
Chest radiograph infiltrates

## Explanation

Back pain, hypotension, and dark-red urine minutes after red cells begin indicate an acute hemolytic transfusion reaction. Stopping the transfusion and infusing 0.9% saline through new tubing limit exposure to incompatible cells and support perfusion. Hourly urine output tracks kidney perfusion as free hemoglobin is cleared, and haptoglobin tracks ongoing hemolysis.

## In-depth explanation

Quick answer
Acute hemolytic transfusion reaction. Stop the transfusion and infuse 0.9% saline through new tubing. Monitor hourly urine output and serum haptoglobin.

Why this is correct
Incompatible red cells are destroyed in the bloodstream within minutes, causing chills, flank or low-back pain, hypotension, and hemoglobinuria. Stopping the unit limits the dose of incompatible cells, and new tubing prevents flushing the rest of the unit into the vein. Free hemoglobin threatens the kidneys, so urine output is followed closely, and haptoglobin (low) with LDH (high) shows whether hemolysis continues.

Easy analogy or mental picture
Imagine the wrong key forced into a lock: the transfused cells are broken apart as they enter, and the pieces (free hemoglobin) clog the kidney's filters. Stop pushing keys in, and keep the filters flushed.

Memory hook
"Back pain + red urine = hemolysis: stop, new saline line, watch the urine."

NCLEX decision rule
When a serious transfusion reaction is suspected, the unit must not keep running, and IV access is maintained with saline through new tubing; choose monitoring that matches the specific reaction pattern.

Why the other choices are wrong
TACO causes hypertension, distended neck veins, and crackles, and the veins are flat with clear lungs, so furosemide and JVD track the wrong reaction. TRALI causes new hypoxemia with bilateral infiltrates, but SpO2 is 96% and lungs are clear, so chest films do not measure this problem. Anaphylaxis brings hives, wheezing, or swelling, which are absent, so IM epinephrine and urticaria checks do not fit. Slowing the rate with acetaminophen is the outdated response for a mild febrile reaction and continues giving incompatible blood.

References
1CDC NHSN Hemovigilance Module ProtocolCase definitions distinguishing acute hemolytic reactions, TACO, TRALI, and allergic reactions (hemoglobinuria, low haptoglobin, raised LDH)
2CDC: Blood Safety — Clinical GuidanceClinicians should recognize and respond to transfusion reactions and report them for hemovigilance

## Clinical scenario

Case update
Chills, low-back pain, hypotension, and hemoglobinuria 12 minutes into a red-cell transfusion.

## Key concepts

- **Hemoglobinuria** — Free hemoglobin in the urine, giving it a red or dark color after intravascular hemolysis.
- **Haptoglobin** — A plasma protein that binds free hemoglobin; a low level indicates ongoing intravascular hemolysis.
- **TACO** — Transfusion-associated circulatory overload: volume excess with hypertension, jugular venous distention, and pulmonary edema.

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