# Situation: A 34-year-old woman is brought to the emergency room (ER) because she nearly fainted at work. She reports fatigue, shortness of breath on climbing stairs, and heavy menstrual periods for the past year. Her heart rate is 118/min and blood pressure 104/66 mmHg. She has no chronic illness and no known drug allergies. Two units of packed red blood cells are ordered. Ten minutes after the first unit is started, she reports chills and low back pain. Her temperature has risen from 37.0 °C to 38.8 °C, and her blood pressure has fallen from 104/66 to 88/54 mmHg. What should the nurse do FIRST?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=629694  
> language: ko  
> subject: Nursing Practice III — Care of Clients with Problems in Surgery, Oxygenation, Fluid and Electrolytes, Infectious, Inflammatory and Immunologic Response, Cellular Aberrations

## 문제

Situation: A 34-year-old woman is brought to the emergency room (ER) because she nearly fainted at work. She reports fatigue, shortness of breath on climbing stairs, and heavy menstrual periods for the past year. Her heart rate is 118/min and blood pressure 104/66 mmHg. She has no chronic illness and no known drug allergies.

Two units of packed red blood cells are ordered. Ten minutes after the first unit is started, she reports chills and low back pain. Her temperature has risen from 37.0 °C to 38.8 °C, and her blood pressure has fallen from 104/66 to 88/54 mmHg. What should the nurse do FIRST?

## 보기

1. Give the prescribed paracetamol and continue the transfusion
2. Notify the provider and blood bank of a possible reaction
3. Stop the blood and run saline through new tubing **✔ 정답**
4. Slow the transfusion and recheck vital signs in 15 minutes

**정답: 3**

## 해설

Fever, chills, low back pain, and falling blood pressure soon after a transfusion starts suggest an acute hemolytic reaction. The first action is to stop the transfusion so no more blood enters, and keep the vein open with normal saline through new tubing. The provider and blood bank are then notified, and the bag and tubing are sent for testing.

## 심화 해설

Why this is an acute hemolytic transfusion reaction
The combination of chills, low back pain, a rapid rise in temperature from 37.0 °C to 38.8 °C, and a fall in blood pressure from 104/66 mmHg to 88/54 mmHg within 10 minutes of starting the first unit strongly suggests an acute hemolytic transfusion reaction (AHTR). AHTR is most often caused by ABO incompatibility, in which recipient antibodies rapidly destroy donor red blood cells inside the blood vessels. This intravascular hemolysis releases free hemoglobin and inflammatory mediators that can progress to shock, acute renal failure, and disseminated intravascular coagulation (DIC) . Low back pain is a particularly important clue because it reflects renal vasoconstriction and ischemic pain triggered by the hemolytic process, not a simple febrile reaction.

Why the first action is to stop the blood and run saline through new tubing
The priority in any suspected AHTR is to immediately stop the transfusion so that no additional incompatible red cells enter the circulation. Every milliliter of remaining donor blood can intensify hemolysis, worsen hypotension, and increase the risk of irreversible kidney injury . After stopping the blood, the intravenous line must be kept open with normal saline using new tubing. The new tubing is essential because the original tubing still contains donor blood; flushing the old line would push more incompatible cells into the patient. The saline infusion supports blood pressure and maintains venous access for emergency medications while the reaction is being evaluated.

Why the other options are incorrect
Watch out! Giving paracetamol and continuing the transfusion delays definitive management and allows ongoing exposure to the offending blood. Paracetamol may reduce fever but does nothing to stop hemolysis or prevent shock and renal failure. Slowing the transfusion and rechecking vital signs in 15 minutes is also unsafe because AHTR can deteriorate rapidly; waiting even a few minutes increases the volume of incompatible blood infused. Notifying the provider and blood bank is a required step, but it must occur after the transfusion has been stopped and the line has been converted to saline. The sequence matters because the patient’s immediate safety depends on interrupting the transfusion first.

Clinical reasoning and nursing priorities
AHTR is a medical emergency because the complications of intravascular hemolysis can be life-threatening . The nurse’s first responsibility is to stop the source of harm. Once the blood is stopped and saline is running through new tubing, the next steps include notifying the provider and blood bank, sending the remaining blood bag and tubing for repeat crossmatch and antibody testing, monitoring urine output for signs of hemoglobinuria, and preparing to support blood pressure and renal perfusion . In trauma settings, AHTR can be especially easy to miss because its early signs may resemble hemorrhage or coagulopathy, which is why a sudden change in vital signs during transfusion must always trigger immediate action .

Key distinctions for the licensure exam

| Finding | Acute hemolytic reaction | Febrile non-hemolytic reaction | Mild allergic reaction |
| --- | --- | --- | --- |
| Onset | Within minutes of starting | Usually within first hour | Minutes to hours |
| Temperature | Rapid rise, often high fever | Rise of 1 °C or more | Usually no fever |
| Key symptoms | Chills, low back pain, hypotension, dark urine | Chills, rigors, headache | Urticaria, itching, flushing |
| First nursing action | Stop transfusion, saline with new tubing | Stop transfusion, notify provider | Stop or slow transfusion depending on severity |

Key point! Low back pain plus fever and hypotension during a transfusion is an acute hemolytic reaction until proven otherwise, and the transfusion must be stopped immediately. The provider and blood bank are notified only after the blood is stopped and the line is converted to normal saline through new tubing.

## 임상 시나리오

Acute Hemolytic Transfusion Reaction: First ResponseStop, Saline, New Tubing, Then Notify
Suspect acute hemolytic transfusion reaction when fever, chills, low back pain, and hypotension develop within 10 minutes of starting a unit. The first action is to stop the transfusion immediately to prevent more incompatible red cells from entering the circulation.

After stopping the blood, keep the vein open with normal saline using new tubing. The original tubing still contains donor blood; flushing it would push more incompatible cells into the patient. Saline supports blood pressure and maintains IV access for emergency medications.

CautionNever restart the same unit or use the old tubing. Send the blood bag, tubing, and a fresh patient blood sample to the blood bank for repeat crossmatch and hemolysis workup. Monitor urine output closely for hemoglobinuria and early acute kidney injury.

## 핵심 개념

- **Acute Hemolytic Transfusion Reaction (AHTR)** — A severe, rapid destruction of donor red blood cells by recipient antibodies, most often due to ABO incompatibility, causing intravascular hemolysis, shock, and potential renal failure.
- **ABO Incompatibility** — A mismatch between donor red blood cell antigens and recipient antibodies that triggers immediate, complement-mediated destruction of transfused red cells.
- **Intravascular Hemolysis** — Destruction of red blood cells within blood vessels, releasing free hemoglobin and inflammatory mediators that can lead to hypotension, DIC, and acute kidney injury.
- **New Tubing** — Replacement of the original transfusion administration set to prevent flushing residual donor blood from the old tubing into the patient.

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