Safe and Effective Care Environment NCLEX RN Questions Related

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A client has just started a transfusion of packed red blood cells that a physician ordered. Which of the following signs may indicate a transfusion reaction?

  • A. The client suddenly complains of back pain and has chills
  • B. The client develops dependent edema in the extremities
  • C. The client has a seizure
  • D. The client's heart rate drops to 60 bpm
Correct Answer: A

Rationale: The correct answer is when the client suddenly complains of back pain and has chills. Signs of a transfusion reaction include back pain, chills, dizziness, increased temperature, and blood in the urine. These signs indicate a possible adverse reaction to the blood transfusion. Dependent edema in the extremities is not typically associated with a transfusion reaction. A seizure is not a common sign of a transfusion reaction unless it is due to severe complications. A decrease in heart rate to 60 bpm is not a typical sign of a transfusion reaction, but rather bradycardia may indicate other underlying conditions or medications.