Blood Transfusion Reaction — NCLEX Cheat Sheet
STOP transfusion → saline first
👤 By the CinnaRN Clinical Content Team
🕐 Updated 2026-07-11
🏷️ Physiological Adaptation
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Use this quick-reference guide to spot, treat, and prevent Blood Transfusion Reaction on the NCLEX. Keep it handy during review and on exam day!
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- STOP transfusion immediately
- keep line open w/ NS (new tubing)
- stay with pt, notify provider
- ABO mismatch = most deadly
- fever, chills, flank/back pain
- red urine, ↓BP, ↑HR, DIC
- allergic: hives, itching → antihistamine
- anaphylaxis: wheeze, ↓BP → epi
- TACO: fluid overload, SOB, crackles
- 2 RN verify pt + blood
- stay first 15 min, vitals
- infuse within 4 hrs
✨Quick Tip
Acute hemolytic reaction (ABO incompatibility) presents with fever, chills, low back/flank pain, hypotension, and dark/red urine.
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