During a red blood cell transfusion, an older client with heart failure develops dyspnea, crackles, jugular venous distention, hypertension, and decreasing oxygen saturation. Which action should the nurse take?
1Stop the transfusion, sit the client upright, provide oxygen, notify the provider and blood bank, and prepare a diuretic.✓ Correct answer
2Slow the transfusion, place the client in Trendelenburg position, and begin an isotonic fluid bolus for hypotension.
3Pause the transfusion briefly, then restart it at half the rate after the oxygen saturation improves.
4Continue the transfusion and administer intramuscular epinephrine because the findings indicate an allergic reaction.
Explanation
Dyspnea, crackles, jugular venous distention, hypertension, and hypoxemia during transfusion are consistent with transfusion-associated circulatory overload. The transfusion is stopped, the client is positioned upright, oxygen and monitoring are provided, the provider and transfusion service are notified, and a loop diuretic is commonly prescribed. Restarting or continuing the component can worsen pulmonary edema.
Clinical reasoning TACO is hydrostatic pulmonary edema caused by volume overload. Hypertension, jugular venous distention, and response to diuresis help distinguish it from noncardiogenic transfusion-related acute lung injury.
Decision rule New respiratory distress during transfusion means stop the component first. For suspected TACO, sit the client upright, support oxygenation, notify the responsible teams, and prepare volume-reduction therapy.
Scenario 82-year-old female CHF receiving 2 units PRBC; 90 min into infusion: acute dyspnea, JVD, BP 178/96, crackles, BNP rising.
TACO — Transfusion-associated circulatory overload; hypervolemia; respond to diuretic.