Nclexrn Quiz: Blood Transfusion Reactions And Immediate Actions
20 questions · exam conditions
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Blood Transfusion Reactions And Immediate ActionsQuestion 1 of 20

A 63-year-old client on a medical-surgical unit is receiving PRBCs. Within 10 minutes, the client reports chills and severe low back pain and the urine in the catheter tubing appears dark; vital signs are T 38.7°C (101.7°F), BP 94/56 mm Hg, HR 126/min, RR 22/min. Which finding requires IMMEDIATE intervention during a blood transfusion?

Mild itching at the adhesive tape site near the intravenous dressing
Client reports fatigue that has been present for several days
Temperature decreases from 37.0°C (98.6°F) to 36.6°C (97.9°F) after a cool cloth
Severe low back pain with dark urine and hypotension shortly after transfusion starts
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Nclexrn Quiz: Blood Transfusion Reactions And Immediate Actions

Practice Blood Transfusion Reactions And Immediate Actions in Nclexrn with focused quiz questions that help you check what you know, review explanations, and build confidence with test-style prompts.

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This quiz focuses on Blood Transfusion Reactions And Immediate Actions, giving you a quick way to practice the rules, question types, and explanations that matter most for Nclexrn.

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Question 1

A 63-year-old client on a medical-surgical unit is receiving PRBCs. Within 10 minutes, the client reports chills and severe low back pain and the urine in the catheter tubing appears dark; vital signs are T 38.7°C (101.7°F), BP 94/56 mm Hg, HR 126/min, RR 22/min. Which finding requires IMMEDIATE intervention during a blood transfusion?

  1. Mild itching at the adhesive tape site near the intravenous dressing
  2. Client reports fatigue that has been present for several days
  3. Temperature decreases from 37.0°C (98.6°F) to 36.6°C (97.9°F) after a cool cloth
  4. Severe low back pain with dark urine and hypotension shortly after transfusion starts (correct answer)
Explanation: This question tests clinical judgment in responding to transfusion reactions, recognizing hemolytic reaction with low back pain, dark urine, and hypotension. The priority concern is client safety and immediate intervention to protect kidneys and circulation. The finding of severe low back pain with dark urine and hypotension shortly after transfusion starts requires immediate intervention as it suggests intravascular hemolysis. Mild itching at tape, chronic fatigue, or temperature decrease are non-acute. The decision-making framework involves stopping the transfusion, forcing diuresis, and checking labs for hemolysis. Monitor urine and vital signs vigilantly. A transferable principle is the safety-first approach in hemolytic crises, using ABCs to prevent multi-organ failure.

Question 2

A 41-year-old client on a medical-surgical unit is receiving PRBCs. Thirty minutes after initiation, the client reports headache and chills; temperature rises from 36.9°C (98.4°F) to 38.1°C (100.6°F), with stable BP and oxygenation. What is the nurse's FIRST action upon recognizing a transfusion reaction?

  1. Administer acetaminophen as prescribed and continue monitoring
  2. Notify the provider and request an order for a blood culture
  3. Obtain a complete set of vital signs every 15 minutes for the next hour
  4. Stop the transfusion and maintain intravenous access with 0.9% sodium chloride using new tubing (correct answer)
Explanation: This question tests clinical judgment in responding to transfusion reactions, spotting a febrile reaction with headache, chills, and mild fever. The priority concern is client safety and immediate intervention to exclude hemolytic or septic causes. Stopping the transfusion and maintaining intravenous access with 0.9% sodium chloride using new tubing addresses the most urgent need by stopping potential triggers. Administering acetaminophen and monitoring is symptomatic only; obtaining vital signs is routine; notifying for blood culture is later. The decision-making framework involves halting the transfusion, evaluating symptom trends, and reporting to the blood bank. Monitor for escalation and provide comfort measures. A transferable principle is the safety-first approach in acute settings, prioritizing intervention halt before further assessment.

Question 3

A 70-year-old client on a medical-surgical unit is receiving packed red blood cells for chronic anemia; the transfusion started 8 minutes ago. The client reports chest tightness and nausea and the nurse notes flushing and dark urine in the catheter bag; vital signs are temperature 38.6 0C (101.5 0F), heart rate 132/min, blood pressure 90/50 mm Hg, respiratory rate 22/min, and oxygen saturation 95% on room air. Which symptom indicates an IMMEDIATE need to stop the transfusion?

  1. Severe low back pain with fever shortly after the transfusion begins (correct answer)
  2. A mild headache during the transfusion that gradually improves with rest
  3. A slight, transient increase in blood pressure during the transfusion without other new findings
  4. Warmth at the intravenous site during the transfusion without swelling, redness, or pain along the vein
Explanation: Severe low back pain with fever shortly after the transfusion begins is the hallmark of an acute hemolytic reaction; the abrupt onset, pain, and fever with hemodynamic instability require stopping the transfusion immediately. The mild headache that gradually improves with rest is self-limited and not accompanied by other reaction signs, so it does not demand immediate cessation. A slight, transient increase in blood pressure without other new findings is not a red flag; in fact, hypotension is the hemodynamic warning in a severe reaction. Warmth at the intravenous site without swelling, redness, or pain along the vein suggests local irritation or normal infusion-related warmth, not an acute systemic reaction. Thus, the priority is identifying the severe back pain with fever as the immediate stop signal, while the other options are minor or localized findings that would not independently require stopping the transfusion.

Question 4

A 50-year-old client on a medical-surgical unit is receiving PRBCs. Within 15 minutes, the client develops fever and chills with severe low back pain; vital signs are T 38.9°C (102.0°F), BP 88/46 mm Hg, HR 132/min, RR 24/min. The nurse should PRIORITIZE which intervention when a transfusion reaction is suspected?

  1. Notify the provider and prepare to administer prescribed antipyretics for a temperature of 38.9°C and chills
  2. Document the reaction in the medical record and complete an incident report per facility policy
  3. Stop the transfusion and maintain the intravenous line with 0.9% sodium chloride using new tubing (correct answer)
  4. Collect blood and urine specimens per the reaction protocol and send them to the laboratory
Explanation: A suspected hemolytic transfusion reaction is an emergency because continued infusion of incompatible blood can worsen hemolysis, shock, and renal injury. The immediate priority is to stop the transfusion and maintain IV access with 0.9% sodium chloride using new tubing; this prevents more blood from being infused and keeps a line open for emergency medications or fluids. Notifying the provider and preparing antipyretics for the fever is important, but it does not stop the incompatible blood product and treats symptoms rather than the source of danger. Documenting the reaction and completing an incident report is an essential follow-up after the client is stabilized, so it cannot be the first intervention. Collecting blood and urine specimens per the reaction protocol and sending them to the laboratory helps confirm the type of reaction, but it is a later step; the nurse must first stop the transfusion and protect the client. Choose the action that directly limits further exposure while preserving venous access.

Question 5

A 47-year-old client is receiving PRBCs on a medical-surgical unit. Thirty-five minutes into the transfusion, the client develops a temperature increase from 36.6°C (97.9°F) to 38.2°C (100.8°F) with mild chills; BP 122/74 mm Hg, HR 98/min, RR 18/min. The nurse should PRIORITIZE which intervention when a transfusion reaction is suspected?

  1. Administer the prescribed acetaminophen to manage the fever and reassess the temperature in one hour
  2. Obtain a focused pain assessment and check the abdomen for tenderness to identify a non-transfusion source
  3. Stop the transfusion and maintain intravenous access with 0.9% sodium chloride using new tubing (correct answer)
  4. Continue the transfusion and encourage oral fluids to help reduce the client's fever and chills
Explanation: Stopping the transfusion is the priority when a febrile reaction is suspected, because halting the blood product prevents further antigen exposure and a potentially more severe response. Maintaining IV access with 0.9% sodium chloride and new tubing ensures that emergency medications and fluids can be administered if the client decompensates. Administering acetaminophen manages the symptom of fever but does nothing to stop the ongoing reaction and could mask a worsening picture; it is a later step, not the priority. A focused pain assessment and abdominal check does not fit the client's fever and chills, which are classic signs of a febrile transfusion reaction, and it delays the critical intervention. Continuing the transfusion while encouraging oral fluids keeps the client exposed to the blood product and does not treat the reaction, placing the client at risk for a more severe complication. Thus, the safe and immediate action is to stop the transfusion and preserve vascular access for further management.

Question 6

A 52-year-old client receiving PRBCs on a medical-surgical unit suddenly develops fever, chills, and severe low back pain 8 minutes after the transfusion begins; vital signs are T 38.8°C (101.8°F), BP 90/52 mm Hg, HR 128/min, RR 22/min. The nurse should PRIORITIZE which intervention when a transfusion reaction is suspected?

  1. Obtain a urine sample and send it to the laboratory for analysis, monitoring for hemoglobinuria
  2. Recheck the blood product label against the client identification band and compare it with the transfusion record
  3. Notify the provider and prepare to administer prescribed vasopressors to treat the worsening hypotensive episode
  4. Stop the transfusion and maintain the intravenous line with 0.9% sodium chloride using new tubing (correct answer)
Explanation: Fever, chills, severe low back pain, and hypotension shortly after starting PRBCs are classic for an acute hemolytic transfusion reaction. The priority is to stop the offending blood from continuing to infuse and to keep venous access open with 0.9% sodium chloride through new tubing; this limits further hemolysis and prepares for possible fluid resuscitation. Obtaining a urine sample and watching for hemoglobinuria are part of the workup, but they do not interrupt the reaction. Rechecking the blood product label and comparing the unit with the transfusion record is a verification step that belongs before administration and, once a reaction is suspected, does not remove the immediate danger. Notifying the provider and preparing vasopressors are necessary after the transfusion is stopped; they do not halt the incompatible blood from being delivered. Thus, stopping the transfusion and maintaining the line takes priority.

Question 7

A 40-year-old client on a medical-surgical unit is receiving PRBCs and develops a temperature rise to 38.4°C (101.1°F) with headache and mild chills; BP and oxygen saturation remain stable. The nurse should PRIORITIZE which intervention when a transfusion reaction is suspected?

  1. Stop the transfusion and keep the intravenous line open with 0.9% sodium chloride using new tubing (correct answer)
  2. Obtain blood cultures from the existing intravenous line before stopping the transfusion to identify the causative organism
  3. Ask about recent sick contacts and vaccination history to determine whether the fever is from an unrelated infection
  4. Continue the transfusion and administer a prescribed antipyretic medication to treat the fever and headache symptomatically
Explanation: When a client receiving PRBCs develops fever, chills, and headache, the priority is to stop the transfusion immediately and maintain vascular access. Keeping the line open with 0.9% sodium chloride and new tubing prevents any remaining blood product from entering and preserves access for treatment. Obtaining blood cultures from the existing intravenous line before stopping the transfusion is wrong because cultures drawn through the transfusion line can be contaminated and the infusion must be halted first. Asking about sick contacts and vaccination history addresses unrelated infection risk, but it does nothing to interrupt a possible transfusion reaction. Continuing the transfusion and giving an antipyretic masks the fever and extends the time the client is exposed to the reaction, so it is unsafe. The correct priority is source removal: stop the blood product, keep a patent saline line with fresh tubing, and then initiate the reaction workup.

Question 8

A 39-year-old client on a medical-surgical unit is receiving PRBCs for iron-deficiency anemia. Thirty minutes into the transfusion, the client's temperature increases from 37.0°C (98.6°F) to 38.3°C (100.9°F) with headache and mild chills; BP 124/78 mm Hg, HR 96/min, RR 18/min, SpO2 99% on room air. The nurse should PRIORITIZE which intervention when a transfusion reaction is suspected?

  1. Obtain a type and screen specimen and send it to the blood bank to verify compatibility before the transfusion is restarted
  2. Continue the transfusion at the current rate and administer the prescribed acetaminophen for the fever and headache while monitoring the client's vital signs
  3. Stop the transfusion and keep the intravenous line open with 0.9% sodium chloride using new tubing (correct answer)
  4. Recheck the client's temperature in thirty minutes and document the fever trend before deciding whether the symptoms are truly caused by the transfusion
Explanation: Fever, headache, and chills during a transfusion should be treated as a suspected reaction until proven otherwise. The safest immediate action is to stop the blood and maintain IV access with 0.9% sodium chloride through new tubing; this removes the possible source of harm and preserves a route for emergency treatment. Continuing the transfusion and giving acetaminophen only treats symptoms and prolongs exposure. Rechecking the temperature in 30 minutes delays the response while a serious reaction may worsen. Obtaining a type and screen is not the priority; it is a later serology step and does not stop the current threat. Therefore, the best choice is to stop the transfusion and keep the IV line open with normal saline using new tubing.

Question 9

A 55-year-old client receiving PRBCs on a medical-surgical unit reports itching and develops scattered hives; vital signs are stable. What is the nurse's FIRST action upon recognizing a transfusion reaction?

  1. Restart the transfusion at a slower rate after the itching and hives have completely resolved
  2. Assess the client's airway and obtain a full set of vital signs to monitor for worsening symptoms
  3. Call the provider to request an order for an antihistamine while continuing to monitor the client's respiratory status
  4. Stop the transfusion and maintain the intravenous line with 0.9% sodium chloride using new tubing (correct answer)
Explanation: In any transfusion reaction, the first action is to stop the blood product because that removes the ongoing source of the antigen. The correct answer also preserves IV access with new tubing and 0.9% sodium chloride, which keeps a route open for emergency medications without exposing the client to more blood from the old tubing. Restarting the transfusion after the hives have resolved is not the first action; the reaction must first be interrupted, and resuming the same product should not happen without careful evaluation and a provider's guidance. Assessing the airway and obtaining vital signs are important monitoring steps, but they do not stop the transfusion, so the client remains exposed to the offending product while the assessment is happening. Calling the provider for an antihistamine also places a later intervention ahead of the immediate safety step; medication may be needed, but it is not the first priority when the antigen is still infusing. The transferable principle is to recognize the reaction and immediately stop the blood while preserving safe venous access.

Question 10

A 67-year-old client with chronic kidney disease on a medical-surgical unit is receiving packed red blood cells for anemia; the transfusion began 50 minutes ago. The client becomes increasingly short of breath with jugular venous distention; vital signs are blood pressure 182/96 mm Hg, heart rate 108/min, respiratory rate 30/min, temperature 36.9°C (98.4°F), and oxygen saturation 86% on 2 L/min nasal cannula. The nurse suspects TACO. The nurse should PRIORITIZE which intervention when a transfusion reaction is suspected?

  1. Stop the transfusion and keep the intravenous line open with 0.9% sodium chloride (correct answer)
  2. Auscultate lung sounds for crackles and document the assessment findings
  3. Administer an intravenous diuretic as prescribed and continue the transfusion at a slower rate
  4. Encourage the client to use incentive spirometry every hour while awake
Explanation: This question tests clinical judgment in responding to transfusion reactions, specifically managing TACO in a high-risk client. The priority concern is preventing further circulatory overload in a client with compromised renal function. Stopping the transfusion and keeping the IV line open with 0.9% sodium chloride (A) is the correct priority action because it immediately halts additional volume loading that is causing respiratory distress and hypertension. Auscultating lung sounds (B) is assessment but doesn't address the urgent problem; administering diuretics while continuing transfusion (C) is contradictory and dangerous; encouraging incentive spirometry (D) won't resolve fluid overload. The decision-making framework prioritizes stopping the source of harm before implementing supportive measures. The transferable principle is that signs of fluid overload during transfusion require immediate cessation, especially in clients with renal or cardiac compromise.

Question 11

A 45-year-old client on a medical-surgical unit is receiving packed red blood cells for symptomatic anemia; the transfusion started 25 minutes ago. The client develops a temperature increase from 37.0°C (98.6°F) to 38.3°C (100.9°F) with mild chills; blood pressure is 128/76 mm Hg, heart rate 96/min, respiratory rate 18/min, and oxygen saturation 97% on room air. The nurse suspects a febrile non-hemolytic transfusion reaction. The nurse should PRIORITIZE which intervention when a transfusion reaction is suspected?

  1. Slow the transfusion rate and reassess the temperature in 15 minutes
  2. Stop the transfusion and keep the intravenous line open with 0.9% sodium chloride (correct answer)
  3. Obtain a blood culture to rule out sepsis from contaminated blood
  4. Administer acetaminophen as prescribed and continue the transfusion if the fever decreases
Explanation: This question tests clinical judgment in responding to transfusion reactions, specifically managing a febrile non-hemolytic transfusion reaction. The priority concern is client safety and preventing potential progression to a more severe reaction. Stopping the transfusion and keeping the IV line open with 0.9% sodium chloride (B) is the correct priority action because any suspected transfusion reaction requires immediate cessation of the transfusion to prevent potential harm. Slowing the rate (A) is inappropriate as it continues exposure to the potentially harmful blood product; obtaining blood cultures (C) may be done later but is not the priority; continuing the transfusion after acetaminophen (D) is dangerous and violates safety protocols. The decision-making framework emphasizes that all transfusion reactions, regardless of severity, require stopping the transfusion first. The transferable principle is that client safety always takes precedence over completing the transfusion, even for mild reactions.

Question 12

A 33-year-old client on a medical-surgical unit is receiving platelets for thrombocytopenia related to chemotherapy; the transfusion began 15 minutes ago. The client reports itching and the nurse notes generalized urticaria (hives); vital signs are temperature 37.1°C (98.8°F), heart rate 88/min, blood pressure 118/70 mm Hg, respiratory rate 16/min, and oxygen saturation 98% on room air. Which finding requires IMMEDIATE intervention during a blood transfusion?

  1. Generalized hives and itching during the transfusion (correct answer)
  2. Mild anxiety about receiving blood products
  3. Temperature increase of 0.2°C (0.4°F) from baseline
  4. Blood pressure unchanged from the pretransfusion baseline
Explanation: This question tests clinical judgment in responding to transfusion reactions, specifically recognizing signs requiring immediate intervention. The priority concern is identifying allergic reactions that could progress to anaphylaxis. Generalized hives and itching during transfusion (A) requires immediate intervention as these are signs of an allergic reaction that could rapidly progress to anaphylaxis with airway compromise. Mild anxiety (B) is common and doesn't require immediate intervention; a temperature increase of 0.2°C (C) is clinically insignificant; unchanged blood pressure (D) is a normal finding. The decision-making framework involves recognizing that allergic manifestations during transfusion require immediate action to prevent progression to life-threatening anaphylaxis. The transferable principle is that any signs of allergic reaction during transfusion demand immediate intervention due to the potential for rapid deterioration.

Question 13

A 58-year-old client on a medical-surgical unit is receiving packed red blood cells for symptomatic anemia; the transfusion started 30 minutes ago. The client reports chills and feels "hot"; temperature is 38.2°C (100.8°F) (baseline 37.0°C [98.6°F]), blood pressure 134/80 mm Hg, heart rate 102/min, respiratory rate 18/min, and oxygen saturation 98% on room air. The nurse suspects a transfusion reaction. What is the nurse's FIRST action upon recognizing a transfusion reaction?

  1. Notify the health care provider and anticipate an order for antipyretics
  2. Stop the transfusion and keep the intravenous line open with 0.9% sodium chloride (correct answer)
  3. Send the remaining blood product and tubing to the blood bank for analysis
  4. Obtain a urine specimen to check for hemoglobinuria
Explanation: This question tests clinical judgment in responding to transfusion reactions, specifically managing febrile reactions. The priority concern is client safety and preventing potential progression of the reaction. Stopping the transfusion and keeping the IV line open with 0.9% sodium chloride (B) is the correct first action because any temperature elevation during transfusion requires immediate cessation to rule out more serious reactions. Notifying the provider for antipyretics (A) comes after stopping the transfusion; sending blood products for analysis (C) is important but secondary; obtaining urine specimens (D) is diagnostic but not the immediate priority. The decision-making framework emphasizes that all suspected reactions require stopping the transfusion first. The transferable principle is that temperature elevation during transfusion always warrants immediate cessation, as it could indicate various types of reactions.

Question 14

A 26-year-old client on a medical-surgical unit is receiving packed red blood cells for postpartum hemorrhage; the transfusion began 12 minutes ago. The client develops wheezing, facial swelling, and difficulty swallowing; vital signs are temperature 37.0°C (98.6°F), heart rate 122/min, blood pressure 86/48 mm Hg, respiratory rate 30/min, and oxygen saturation 90% on room air. What is the nurse's FIRST action upon recognizing a transfusion reaction?

  1. Stop the transfusion and keep the intravenous line open with 0.9% sodium chloride (correct answer)
  2. Administer epinephrine intramuscularly as prescribed
  3. Obtain a full set of vital signs and document the findings
  4. Call the blood bank to request a different unit of blood
Explanation: This question tests clinical judgment in responding to transfusion reactions, specifically managing anaphylactic reactions. The priority concern is client safety in a life-threatening allergic reaction with airway compromise. Stopping the transfusion and keeping the IV line open with 0.9% sodium chloride (A) is the correct first action because it immediately removes the allergen while maintaining vascular access for emergency medications. Administering epinephrine (B) is critical but comes immediately after stopping the transfusion; obtaining vital signs (C) delays urgent intervention; calling for a different unit (D) is inappropriate during an emergency. The decision-making framework follows the ABCs with immediate removal of the causative agent. The transferable principle is that in anaphylactic reactions, stopping exposure to the allergen is the first priority, followed immediately by emergency interventions.

Question 15

A 74-year-old client with heart failure is receiving PRBCs on a medical-surgical unit. One hour into the transfusion, the client becomes restless and dyspneic with crackles and frothy sputum; vital signs are BP 184/100 mm Hg, HR 114/min, RR 30/min, SpO2 85% on 2 L/min nasal cannula. Which symptom indicates an IMMEDIATE need to stop the transfusion?

  1. Client reports mild nausea after taking oral iron
  2. Heart rate increases from 82/min to 92/min after talking with family
  3. Acute dyspnea with crackles and frothy sputum during transfusion (correct answer)
  4. Client reports dry mouth and asks for ice chips
Explanation: This question tests clinical judgment in responding to transfusion reactions, identifying TACO with acute dyspnea, crackles, and frothy sputum. The priority concern is client safety and immediate intervention to resolve pulmonary congestion. The symptom of acute dyspnea with crackles and frothy sputum during transfusion indicates an immediate need to stop the transfusion due to overload risk. Mild nausea, heart rate increase, or dry mouth are minor and not indicative. The decision-making framework involves halting the transfusion, administering oxygen, and positioning upright. Monitor for improvement and administer diuretics as needed. A transferable principle is the safety-first approach in overload, applying ABCs for respiratory rescue.

Question 16

A 66-year-old client receiving PRBCs on a medical-surgical unit reports new onset of wheezing and tightness in the throat 5 minutes after the transfusion starts; vital signs are BP 110/68 mm Hg, HR 104/min, RR 24/min, SpO2 92% on room air with hives noted. Which symptom indicates an IMMEDIATE need to stop the transfusion?

  1. Client reports mild tenderness at the intravenous site
  2. Temperature increases from 36.7°C (98.1°F) to 37.2°C (99.0°F)
  3. Client requests to use the restroom shortly after the transfusion begins
  4. New wheezing and throat tightness during transfusion (correct answer)
Explanation: This question tests clinical judgment in responding to transfusion reactions, identifying anaphylactic symptoms like wheezing, throat tightness, and hives. The priority concern is client safety and immediate intervention to protect the airway. The symptom of new wheezing and throat tightness during transfusion indicates an immediate need to stop the transfusion due to risk of bronchospasm and edema. Mild IV site tenderness, slight temperature increase, or restroom request are benign and lower priority. The decision-making framework involves halting the transfusion, assessing airway patency, and preparing epinephrine if needed. Monitor vital signs and administer antihistamines or steroids as prescribed. A transferable principle is the safety-first approach in anaphylaxis, prioritizing ABCs and allergen removal.

Question 17

A 56-year-old client with a history of multiple prior transfusions is receiving PRBCs on a medical-surgical unit. Twenty minutes after starting the transfusion, the client develops sudden severe dyspnea and anxiety; vital signs are T 37.1°C (98.8°F), BP 104/62 mm Hg, HR 118/min, RR 34/min, SpO2 82% on room air with new bilateral crackles. What is the nurse's FIRST action upon recognizing a transfusion reaction?

  1. Call the rapid response team and prepare for possible intubation
  2. Raise the head of the bed and apply oxygen at a higher flow rate
  3. Stop the transfusion and maintain the intravenous line with 0.9% sodium chloride using new tubing (correct answer)
  4. Administer furosemide as prescribed for suspected fluid overload
Explanation: This question tests clinical judgment in responding to transfusion reactions, such as transfusion-related acute lung injury (TRALI) indicated by severe dyspnea, hypoxia, and crackles. The priority concern is client safety and immediate intervention to prevent further pulmonary damage. Stopping the transfusion and maintaining the intravenous line with 0.9% sodium chloride using new tubing addresses the most urgent need by ceasing the infusion of potential antibodies causing the reaction. Raising the head of the bed and increasing oxygen is supportive but not first; calling rapid response is subsequent; administering furosemide is for overload but assumes diagnosis without stopping the source. The decision-making framework includes halting the transfusion immediately, supporting oxygenation, and assessing for deterioration. Closely monitor vital signs and prepare for advanced respiratory support if needed. A transferable principle is the ABCs in acute respiratory distress, emphasizing removal of the inciting factor before symptomatic management.

Question 18

A 28-year-old client on a medical-surgical unit is receiving PRBCs. Fifteen minutes into the transfusion the client develops generalized hives and pruritus; vital signs remain stable. Which symptom indicates an IMMEDIATE need to stop the transfusion?

  1. New onset of hives and itching during the transfusion (correct answer)
  2. Client reports mild incisional pain rated 3/10 after repositioning
  3. Client reports hunger and asks when dinner will arrive
  4. Temperature remains 36.8°C (98.2°F) with no change from baseline
Explanation: This question tests clinical judgment in responding to transfusion reactions, detecting an allergic reaction with new hives and itching amid stable vitals. The priority concern is client safety and immediate intervention to halt progression. The symptom of new onset of hives and itching during the transfusion indicates an immediate need to stop the transfusion to avoid worsening allergy. Hunger, stable temperature, or mild pain are non-urgent and unrelated. The decision-making framework includes halting the transfusion, observing for resolution, and documenting the event. Prepare for antihistamine administration if symptoms persist. A transferable principle is the ABCs in allergic scenarios, ensuring trigger elimination for client stability.

Question 19

A 64-year-old client with gastrointestinal bleeding is receiving PRBCs on a medical-surgical unit. Five minutes after initiation, the client reports chest tightness and low back pain and appears restless; vital signs are T 38.2°C (100.8°F), BP 86/48 mm Hg, HR 130/min, RR 26/min. Which symptom indicates an IMMEDIATE need to stop the transfusion?

  1. Nausea after eating lunch with no change in respiratory status
  2. Mild anxiety related to hospitalization with stable vital signs
  3. Low back pain with hypotension and fever shortly after transfusion begins (correct answer)
  4. Slight increase in heart rate after ambulating to the bathroom
Explanation: This question tests clinical judgment in responding to transfusion reactions, recognizing acute hemolytic symptoms like low back pain, hypotension, fever, chest tightness, and restlessness. The priority concern is client safety and immediate intervention to avert disseminated intravascular coagulation or shock. The symptom of low back pain with hypotension and fever shortly after transfusion begins indicates an immediate need to stop the transfusion due to possible hemolysis. Mild anxiety, nausea, or slight heart rate increase are nonspecific and lower priority without acute changes. The decision-making framework includes halting the transfusion right away, maintaining IV access, and assessing for bleeding or renal involvement. Monitor urine output and vital signs closely for signs of complications. A transferable principle is applying the ABCs in hemolytic crises, ensuring rapid intervention to stabilize circulation and prevent organ damage.

Question 20

A 70-year-old client with a history of heart failure is receiving PRBCs on a medical-surgical unit for symptomatic anemia. Halfway through the unit, the client becomes increasingly dyspneic with crackles at the lung bases; vital signs are BP 176/94 mm Hg, HR 110/min, RR 28/min, SpO2 88% on 2 L/min nasal cannula. Which finding requires IMMEDIATE intervention during a blood transfusion?

  1. Client reports feeling sleepy and requests to rest
  2. Temperature increase from 36.8°C (98.2°F) to 37.4°C (99.3°F)
  3. Mild soreness at the intravenous insertion site without swelling
  4. Crackles with rising blood pressure and worsening shortness of breath (correct answer)
Explanation: This question tests clinical judgment in responding to transfusion reactions, focusing on recognizing transfusion-associated circulatory overload (TACO) with symptoms like crackles, hypertension, and dyspnea. The priority concern is client safety and immediate intervention to address respiratory compromise and fluid overload. The finding of crackles with rising blood pressure and worsening shortness of breath requires immediate intervention as it indicates pulmonary edema from volume overload. A mild temperature increase may suggest a febrile reaction but is less urgent; soreness at the IV site is common and not critical; feeling sleepy is nonspecific and low priority. The decision-making framework involves stopping the transfusion promptly, positioning the client upright, and administering oxygen while monitoring cardiac status. Notify the provider for diuretics or further interventions as needed. A transferable principle is the safety-first approach in acute settings, applying the ABCs to prioritize respiratory and circulatory stability.