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NCLEX · Safety and Infection Control

A client receiving a blood transfusion reports sudden onset of lower back pain, chills, and feeling flushed 15 minutes into the transfusion. What is the FIRST nursing action?

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Correct answer

Stop the transfusion immediately — these symptoms indicate a potential acute haemolytic transfusion reaction (ABO incompatibility), which is life-threatening; stopping the transfusion is the absolute first action; do not remove the IV

  1. A Stop the transfusion immediately — these symptoms indicate a potential acute haemolytic transfusion reaction (ABO incompatibility), which is life-threatening; stopping the transfusion is the absolute first action; do not remove the IV
  2. B Slow the transfusion rate
  3. C Administer diphenhydramine and continue
  4. D Call the blood bank first

Why this is the answer

ACUTE HAEMOLYTIC TRANSFUSION REACTION (AHTR):

Mechanism: ABO incompatibility — transfused red cells are destroyed by recipient's antibodies; severe inflammatory cascade.

Symptoms: Lower back pain (classic — renal pain from haemoglobinuria); fever/chills; flushing; hypotension; haematuria.

Life-threatening: Can cause acute renal failure, DIC, shock, and death.

Immediate response: STOP the transfusion FIRST — every additional millilitre of incompatible blood worsens the reaction; keep IV line patent (NS); notify RN and blood bank immediately; vital signs; obtain urine specimen; keep blood bag and tubing for blood bank analysis; return blood unit to blood bank; anticipate: IV fluids (maintain renal perfusion); diuretics; vasopressors if needed; CONTRAST WITH FEBRILE NON-HAEMOLYTIC REACTION: Just fever and chills without back pain/haematuria — less serious.

Compare with allergic: Urticaria/hives — slow or stop transfusion, give diphenhydramine, may restart.

Anaphylaxis: Airway symptoms — stop permanently, epinephrine.

Key: ANY symptomatic blood reaction = STOP transfusion FIRST.

Source: NCLEX-PN Safe Care — Blood Transfusion, Haemolytic Reaction Response

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About this topic: Safety and Infection Control

Safety and infection control questions cover Standard and transmission-based precautions, hand hygiene, fall and injury prevention, restraints, fire safety and handling hazardous materials. This is one of 35 PN: Coordinated Care questions on safety and infection control, each with a full explanation on a single study page.

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