Editing Medical-Surgical Nursing – RN Practice Questions (section)

==Question 10==
Fifteen minutes after a unit of packed red blood cells is started, a patient develops chills, a temperature increase of 2 degrees Fahrenheit, low back pain, and dark red urine. Which action should the nurse take first?
# Notify the provider and the blood bank.
# Stop the transfusion immediately.
# Obtain a urine specimen for analysis.
# Administer the prescribed antipyretic.

'''Answer:''' Option 2, stop the transfusion immediately.

''Rationale:'' Chills, fever, flank or low back pain, and hemoglobinuria indicate an acute hemolytic transfusion reaction, which is life threatening. Stopping the infusion halts further exposure and is always the first action. The nurse then keeps the line open with normal saline using new tubing, assesses vital signs, notifies the provider and blood bank (option 1), and collects specimens including urine (option 3). Option 4 treats a symptom without stopping the cause and is not first.