NCLEX Question of the Day – Wednesday, May 20, 2026

Today’s question targets Med-Surg prioritization and early recognition of transfusion reactions. This matters because a patient can look stable one minute and become critically ill the next if warning signs are missed. Nurses are often the first to notice the change, stop the trigger, and prevent harm.

Clinical Scenario

A 68-year-old patient is on a medical-surgical unit after a right hemicolectomy for colon cancer. The patient has a history of hypertension and chronic kidney disease stage 3. Morning labs show hemoglobin 6.9 g/dL, so the provider prescribed 1 unit of packed red blood cells. The nurse verifies the blood with another licensed nurse and begins the transfusion at a slow rate.

Fifteen minutes later, the patient says, “I feel suddenly very cold,” and reports tightness in the lower back. The nurse notes new chills, a temperature increase from 98.4 F to 100.1 F, heart rate 112/min, blood pressure 146/88 mm Hg, and oxygen saturation 95% on room air. The IV site is patent, and the blood has infused only a small amount.

The Question

What is the nurse’s priority action?

Answer Choices

1. A. Slow the transfusion rate and stay with the patient to reassess vital signs in 15 minutes.
2. B. Stop the transfusion, disconnect the blood tubing, keep the vein open with normal saline using new tubing, and notify the provider and blood bank.
3. C. Administer prescribed acetaminophen for fever and continue the transfusion because mild reactions are expected.
4. D. Document the findings as postoperative discomfort and ask the provider for an order for a heating pad for back pain.

Correct Answer

B. Stop the transfusion, disconnect the blood tubing, keep the vein open with normal saline using new tubing, and notify the provider and blood bank.

Detailed Rationale

This patient is showing signs of an acute transfusion reaction. The key clues are chills, fever, and low back pain shortly after the transfusion started. Back pain matters here because it can point to hemolysis, which can rapidly damage the kidneys and trigger shock. Even though the temperature rise seems small, the timing is what makes it dangerous. A new symptom that appears within minutes of starting blood is never something to “watch and wait.”

The nurse’s first job is to stop the source of harm. That means stopping the blood transfusion immediately. Do not just slow it down. If the blood product is causing the reaction, any continued infusion can worsen the response.

Next, the nurse should maintain IV access with normal saline using new tubing. This is important for two reasons. First, the patient may need emergency medications or fluids. Second, using new tubing avoids infusing any more of the blood product that may still be in the original line.

After stopping the transfusion, the nurse should assess and monitor the patient closely. Recheck vital signs, assess airway and breathing, and watch for signs of worsening instability such as hypotension, dyspnea, wheezing, chest pain, anxiety, flushing, or dark urine. The nurse should also verify the patient and blood product identification according to policy, because incompatibility errors can be life-threatening.

Then the nurse should notify the provider and the blood bank. Most facilities require a transfusion reaction workup. This may include sending the remaining blood bag and tubing to the blood bank and obtaining blood and urine samples. Monitoring urine output is especially important because hemolysis can lead to acute kidney injury.

In real nursing practice, the order of thinking is simple: stop the transfusion, support the patient, save the line with saline, and escalate fast. You do not need to determine the exact type of reaction before acting. The symptoms are enough to treat this as urgent.

Why the Other Options Are Wrong

A. Slow the transfusion rate and stay with the patient to reassess vital signs in 15 minutes.

This delays treatment and leaves the trigger in place. A suspected transfusion reaction is not managed by reducing the rate. The blood must be stopped right away. Waiting 15 minutes could allow the reaction to progress.

C. Administer prescribed acetaminophen for fever and continue the transfusion because mild reactions are expected.

This is unsafe. A fever during transfusion may be benign in some cases, but fever with chills and back pain raises concern for a more serious reaction. The nurse should never assume a reaction is minor while the blood is still running. Symptom treatment comes after the transfusion is stopped and the patient is fully assessed.

D. Document the findings as postoperative discomfort and ask the provider for an order for a heating pad for back pain.

This ignores the pattern. Postoperative pain does not usually appear suddenly with chills and a temperature rise right after blood is started. The timing makes transfusion reaction the priority concern. A heating pad would treat the wrong problem and waste time.

Key Takeaways

• New chills, fever, back pain, dyspnea, chest tightness, or hypotension during a transfusion should be treated as a possible transfusion reaction.
• The first action is to stop the transfusion. Do not slow it and do not “see if it passes.”
• Keep the IV line open with normal saline using new tubing.
• Reassess vital signs, airway, breathing, urine output, and overall stability.
• Notify the provider and blood bank and follow facility policy for reaction workup.

What you’d do on shift: stay with the patient, stop the blood, hang normal saline with fresh tubing, get a full set of vital signs, check lung sounds and symptoms, verify identifiers, call the provider and blood bank, and prepare to send the blood bag and tubing if required.

Quick Practice Extension

1. A patient develops itching and hives 20 minutes into a transfusion but has no fever, dyspnea, or hypotension. What should the nurse assess first before anticipating the next intervention?

2. After a suspected hemolytic transfusion reaction, which finding should the nurse watch most closely in the next several hours: urine output, bowel sounds, capillary refill, or appetite?

Questions like this test more than memorization. They test whether you can recognize a dangerous pattern, act in the right order, and protect the patient before the full diagnosis is confirmed. That is exactly what safe bedside nursing requires.

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