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Nursing QUESTION #9304
Question 1
A nurse is preparing to administer a blood transfusion. The patient develops sudden onset of chills, fever, back pain, and hemoglobinuria 30 minutes into the transfusion. The most likely complication is:
  • Febrile non-hemolytic transfusion reaction
  • Allergic urticarial reaction
  • Acute hemolytic transfusion reaction (ABO incompatibility)✔️
  • Transfusion-associated circulatory overload (TACO)
Correct Answer Explanation

Acute Hemolytic Transfusion Reaction (AHTR) — most dangerous transfusion complication, usually due to ABO incompatibility:

  • Onset: within first 15–30 minutes of transfusion
  • Symptoms: fever, chills, back/flank pain (renal involvement), hemoglobinuria (red/brown urine), hypotension, anxiety, sense of doom
  • Mechanism: Antibodies destroy transfused RBCs → intravascular hemolysis → free hemoglobin → acute renal failure

Immediate nursing actions (STOP-STAY-SUPPORT):

  1. Stop the transfusion immediately
  2. Keep IV line open with normal saline
  3. Notify physician and blood bank STAT
  4. Send blood and urine samples to blood bank
  5. Monitor vital signs every 5 minutes
  6. Return blood bag and tubing to blood bank
  7. Monitor urine output — maintain >100 mL/hr (prevent renal failure)