# A 58-year-old client with anemia from gastrointestinal bleeding is receiving the first unit of packed red blood cells. Pretransfusion vital signs were temperature 36.9 C (98.4 F), heart rate 88/min, and blood pressure 128/74 mm Hg. Ten minutes after the transfusion starts, the client reports chills, low back pain, and shortness of breath. Temperature is now 38.5 C (101.3 F), heart rate 124/min, blood pressure 86/48 mm Hg, and oxygen saturation 93% on room air. Lung sounds are clear, neck veins are flat, and no rash, hives, or wheezing is present. Dark red-brown urine appears in the catheter drainage bag. 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=617409&lang=en  
> language: en  
> subject: Complications of Procedures  
> category: ROR

## Question

A 58-year-old client with anemia from gastrointestinal bleeding is receiving the first unit of packed red blood cells. Pretransfusion vital signs were temperature 36.9 C (98.4 F), heart rate 88/min, and blood pressure 128/74 mm Hg. Ten minutes after the transfusion starts, the client reports chills, low back pain, and shortness of breath. Temperature is now 38.5 C (101.3 F), heart rate 124/min, blood pressure 86/48 mm Hg, and oxygen saturation 93% on room air. Lung sounds are clear, neck veins are flat, and no rash, hives, or wheezing is present. Dark red-brown urine appears in the catheter drainage bag. 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
Febrile nonhemolytic transfusion reaction
Acute hemolytic transfusion reaction
Anaphylactic transfusion reaction
Transfusion-associated circulatory overload

Actions to take

Select 2
Give prescribed acetaminophen, then resume slowly
Administer prescribed epinephrine intramuscularly
Slow the transfusion and recheck in 15 minutes
Stop the transfusion and keep the blood bag
Infuse 0.9% sodium chloride through new tubing

Parameters to monitor

Select 2
Hourly urine output and color
Extent of urticaria on the trunk
Serum B-type natriuretic peptide
Blood pressure and heart rate
Temperature every 4 hours

## Explanation

Onset within minutes with fever, back pain, hypotension, and hemoglobinuria indicates an acute hemolytic reaction, most often from ABO incompatibility. The nurse stops the transfusion, keeps the bag for the blood bank, and maintains IV access and renal perfusion with normal saline through new tubing. Urine output and color and blood pressure with heart rate show whether shock and renal injury are being controlled. Clear lungs, flat neck veins, and absent hives exclude overload and anaphylaxis.

## In-depth explanation

Quick answer
Acute hemolytic transfusion reaction; stop the transfusion and keep the bag, infuse normal saline through new tubing, and monitor hourly urine output and color along with blood pressure and heart rate.

Why this is correct
Fever alone could be a febrile nonhemolytic reaction, but this client also has back pain, hypotension, and dark urine, which signal intravascular hemolysis. New tubing avoids giving more of the incompatible blood still in the line, and saline supports blood pressure and urine flow to protect the kidneys from free hemoglobin.

Easy analogy or mental picture
Picture the wrong key forced into a lock: the red cells burst open, and the debris (hemoglobin) clogs the kidneys, darkening the urine.

Memory hook
Fever + back pain + dark urine in the first minutes = hemolysis: stop, save, saline, new line.

NCLEX decision rule
For any suspected transfusion reaction, stop the product first; then use the accompanying signs to name the type and choose what to monitor.

Why the other choices are wrong
A febrile nonhemolytic reaction causes fever and chills without hypotension or hemoglobinuria, so acetaminophen and resuming the unit are unsafe here. Anaphylaxis would bring hives, wheezing, or angioedema, and it does not cause fever or dark urine, so epinephrine and urticaria checks do not fit. Circulatory overload causes hypertension, crackles, and distended neck veins, so BNP is not the right marker. Slowing the rate continues exposure to incompatible blood. Temperature every 4 hours is too infrequent and nonspecific.

References
1MedlinePlus — Hemolytic transfusion reactionSymptoms include fever, chills, back pain, and dark urine; the transfusion must be stopped.
2CDC NHSN — Hemovigilance Module ProtocolDefines acute hemolytic, febrile nonhemolytic, allergic, and TACO reaction criteria.

## Clinical scenario

Scenario
Ten minutes into a packed red blood cell transfusion, a client develops fever, chills, low back pain, dyspnea, hypotension, and dark urine, with clear lungs and no hives.

## Key concepts

- **Hemoglobinuria** — Free hemoglobin in the urine from red cell destruction, producing red or brown urine.
- **ABO incompatibility** — Transfusion of red cells that the recipient's antibodies attack, causing acute intravascular hemolysis.
- **TACO** — Transfusion-associated circulatory overload: pulmonary edema from volume excess during transfusion.

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