Blood Transfusions and Transfusion Reactions

Medical-Surgical · Hematology / Oncology·Updated 2026-10-28

What it is

A transfusion replaces red cells, platelets, plasma or clotting factors. The most dangerous reaction, acute hemolytic, occurs when ABO-incompatible red cells are given and the client's antibodies destroy them; it almost always results from an identification error. Because severe reactions begin within minutes, safety depends on bedside verification, slow initial infusion with the nurse present, and stopping the transfusion at the first sign of a reaction.

What the NCLEX focuses on

Bedside verification by two qualified licensed staff (or per the bar-code policy): two client identifiers, ABO and Rh type, unit number and expiration date, matched to the prescription.
Prime and flush with 0.9% sodium chloride through blood tubing with a filter; never dextrose solutions or medications in the line.
Acute hemolytic reaction: fever, chills, low back or flank pain, chest tightness, hypotension, tachycardia and dark red-brown urine.
Febrile nonhemolytic reaction (fever, chills) is the most common; leukocyte-reduced products prevent it. Allergic reactions cause hives and itching; anaphylaxis adds wheezing and hypotension.
Transfusion-associated circulatory overload: dyspnea, crackles, hypertension and jugular venous distention, especially in older adults and clients with heart failure.
Transfusion-related acute lung injury: sudden hypoxemia and bilateral infiltrates within 6 hours, usually with hypotension and fever.
Assistive personnel can measure and report vital signs; verification, initiation and assessment for reactions stay with the RN.

Priority nursing actions

Stop the transfusion immediately.
Disconnect the blood tubing at the hub and keep the IV open with 0.9% sodium chloride through new tubing.
Assess vital signs, airway and breathing, and notify the provider and the blood bank.
Give prescribed treatment: epinephrine for anaphylaxis, a diuretic and upright position for overload, an antipyretic or antihistamine for mild reactions.
Recheck labels and identification; send the bag, tubing and prescribed blood and urine samples to the blood bank, and document.

Numbers to know

Rule	Value	Why it matters
Start after release from the blood bank	Within 30 minutes	Limits bacterial growth and cell damage
Infusion time per unit	Complete within 4 hours	Longer infusion raises contamination risk
Close observation	First 15 minutes, nurse at the bedside	Most severe reactions begin early
Vital signs	Before, at 15 minutes, then per policy and at completion	Detects fever, hypotension, tachycardia
Hemoglobin threshold, stable adult	7 g/dL (70 g/L); 8 g/dL (80 g/L) with cardiovascular disease	Restrictive transfusion practice
Expected rise per unit of red cells	Hemoglobin about 1 g/dL (10 g/L); hematocrit about 3%	Evaluates the response

Common exam traps

Choosing to slow the transfusion and reassess when chills and back pain begin: wrong because any suspected reaction requires stopping the transfusion.
Choosing to flush the existing blood tubing with saline: wrong because it pushes more incompatible blood into the client.
Choosing 5% dextrose in water to keep the line open: wrong because dextrose hemolyzes red cells.
Choosing to delegate bedside verification or assessment for a reaction to assistive personnel: wrong because both require RN judgment.

What to teach

During the transfusion, report chills, itching, back pain, shortness of breath or a sense that something is wrong at once.
After the transfusion, report fever, dark urine or yellowing of the skin or eyes over the next days to weeks, which signals a delayed hemolytic reaction.

Try 2 NCLEX-style questions on this topic

From the NCLEXPace question bank. Pick your answers, then check them inside NCLEXPace.

Question 1 · QID 02048CC9

A 7-year-old weighing 25 kg is receiving 300 mL of packed red blood cells over 3 hours. For each finding noted 20 minutes into the transfusion, indicate whether the nurse should continue the transfusion or stop it immediately.

For each finding, identify whether the nurse should continue or stop the transfusion.

	Continue the transfusion	Stop the transfusion immediately
Temperature rise from 37.0 C (98.6 F) to 38.4 C (101.1 F) with shaking chills
Heart rate decrease from 118/min to 104/min
New hives across the neck and chest with audible wheezing
Anxiety about the IV that settles when the parent reads a story aloud
Report of low back pain with dark red-brown urine in the collection hat

Question 2 · QID E0F2989A

A 4-month-old with severe combined immunodeficiency identified by newborn screening is admitted with pneumonia and a hemoglobin of 7.2 g/dL while awaiting stem cell transplant. Which prescription should the nurse question?

Select the best answer.

A. Admit to a private positive-pressure room with protective precautions and restrict exposure to visitors with infectious symptoms
B. Trimethoprim-sulfamethoxazole on the prescribed schedule for Pneumocystis jirovecii pneumonia prophylaxis
C. IVIG 400 mg/kg IV every 4 weeks with routine infusion monitoring for reactions and clinical response
D. Transfuse 15 mL/kg of standard leukoreduced packed red blood cells over 3 hours

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Sources

Harding MM, Kwong J, Hagler D, Reinisch C. Lewis's Medical-Surgical Nursing: Assessment and Management of Clinical Problems. 12th ed. Elsevier; 2023; Chapter: Hematologic Problems.
Carson JL, Stanworth SJ, Guyatt G, et al. Red Blood Cell Transfusion: 2023 AABB International Guidelines. JAMA. 2023;330(19):1892-1902.
National Council of State Boards of Nursing, American Nurses Association. National Guidelines for Nursing Delegation. NCSBN; 2019.

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