NCLEX Question of the Day – Friday, February 20, 2026

Today’s question targets safe transfusion management and first-response prioritization. Reactions to blood products can turn critical fast. Nurses are the safety net: early recognition and the very first action determine outcomes. This is core on the NCLEX and on the floor.

Clinical Scenario

A 64-year-old patient on a medical-surgical unit is receiving 1 unit of packed red blood cells for symptomatic anemia after a GI bleed. Past history includes hypertension and stage 2 chronic kidney disease. Fifteen minutes into the transfusion, the patient reports chills and “tightness” in the chest. You note a temperature of 38.9 C (up from 37.2 C pre-transfusion), new low back pain, dyspnea, and dark, tea-colored urine in the foley bag. Blood pressure is now 96/58 (down from 118/72), heart rate 118, SpO2 90% on 2 L nasal cannula.

The Question

Which action should the nurse take first?

Answer Choices

1. A. Stop the transfusion and keep the IV line open with normal saline using new tubing.
2. B. Administer acetaminophen for fever per PRN order.
3. C. Slow the transfusion rate and reassess in 15 minutes.
4. D. Notify the provider and obtain a urine sample for hemolysis testing.

Correct Answer

A. Stop the transfusion and keep the IV line open with normal saline using new tubing.

Detailed Rationale

The presentation strongly suggests an acute hemolytic transfusion reaction. Hallmarks include fever, chills, back or flank pain, dyspnea, hypotension, and hemoglobinuria (dark urine). This reaction is often due to ABO incompatibility and can rapidly progress to shock, acute kidney injury, and disseminated intravascular coagulation.

The first and most critical action is to stop the source of harm: the blood transfusion. Every additional milliliter increases hemolysis and worsens organ injury. After stopping the transfusion, keep the IV line patent by hanging 0.9% normal saline with new tubing. You need patent access to support blood pressure, give emergency meds, and draw labs. Using new tubing prevents infusing residual blood.

Immediate nursing steps after stopping the transfusion:

• Maintain airway and breathing: increase oxygen as needed to keep SpO2 ≥ 94%. Position for comfort and ventilation.
• Assess circulation: frequent blood pressure, heart rate, respiratory rate, temperature, and SpO2. Watch for signs of shock.
• Notify the provider and the blood bank promptly once the transfusion is stopped and IV access is secured with saline.
• Recheck patient and blood product ID bands against the order to identify potential mismatch.
• Save the blood bag and tubing; send them to the blood bank per protocol.
• Anticipate orders: CBC, type and screen/crossmatch, direct antiglobulin (Coombs) test, hemolysis labs (plasma free Hgb, bilirubin, LDH), basic metabolic panel, coagulation studies, and urinalysis for hemoglobin.
• Monitor urine output closely (≥ 0.5 mL/kg/hr goal). Hemoglobin released during hemolysis can obstruct renal tubules; early fluids may protect kidneys if not contraindicated.
• Document events, times, vital signs, interventions, and patient response accurately.

Why this order of operations? ABCs and “stop the source” drive priorities. Stopping the transfusion halts the antigen-antibody reaction. Keeping the line open enables rapid support. Calling the provider and collecting specimens are essential, but they come after safety-critical actions.

Why the Other Options Are Wrong

• B. Administer acetaminophen for fever per PRN order. Treating the fever does not address the cause. Antipyretics can mask worsening symptoms and delay the life-saving step of stopping the transfusion. This is symptomatic care, not a safety action.
• C. Slow the transfusion rate and reassess in 15 minutes. Any suspected transfusion reaction requires immediate cessation. Slowing the rate continues antigen exposure and increases the risk of shock, kidney injury, and DIC. This is unsafe.
• D. Notify the provider and obtain a urine sample for hemolysis testing. These are correct and necessary—after the transfusion is stopped and the IV is kept open with saline. Calling first without stopping the transfusion prolongs exposure to the offending blood product.

Key Takeaways

• Recognize acute hemolytic reaction: fever/chills, back pain, dyspnea, hypotension, dark urine, anxiety, chest tightness.
• First action: stop the transfusion immediately; keep IV patent with normal saline using new tubing.
• Then notify the provider and blood bank, monitor ABCs and vitals, save the bag/tubing, and prepare for labs.
• Watch urine output and renal function; hemolysis can cause acute kidney injury.
• Never “slow and watch” when a transfusion reaction is suspected.

• On-shift mini-checklist:
  • Stop blood → Hang NS with new tubing → Airway/O2 → Rapid vitals
  • Call provider/blood bank → Recheck IDs → Save bag/tubing
  • Collect labs/urine → Strict I&O → Document precisely

Quick Practice Extension

• Before starting a transfusion, which two patient identifications and product checks most reduce the risk of an acute hemolytic reaction, and how do you perform them at the bedside?
• A patient develops fever and chills 45 minutes into a transfusion but no dyspnea, hypotension, or back pain. What sequence of actions and assessments helps you differentiate a febrile nonhemolytic reaction from other reaction types?

G S Sachin

I am a Registered Pharmacist under the Pharmacy Act, 1948, and the founder of PharmacyFreak.com. I hold a Bachelor of Pharmacy degree from Rungta College of Pharmaceutical Science and Research. With a strong academic foundation and practical knowledge, I am committed to providing accurate, easy-to-understand content to support pharmacy students and professionals. My aim is to make complex pharmaceutical concepts accessible and useful for real-world application.

Mail- Sachin@pharmacyfreak.com