An older adult with heart failure and chronic kidney disease is prescribed 2 units of red blood cells for symptomatic anemia and is not actively bleeding. Complete the plan to reduce and respond to transfusion-associated circulatory overload risk.
Drop-down Cloze
Choose your responses, then check the answer.
Explanation
Older age, heart failure, kidney dysfunction, transfusion volume, and infusion rate can increase TACO risk. A risk-reduction plan may use one unit followed by reassessment before an additional unit, a controlled slower rate or split unit when ordered and appropriate, and close monitoring. New dyspnea, hypertension, jugular venous distention, crackles, or hypoxemia during or soon after transfusion requires stopping the transfusion, placing the client upright as tolerated, notifying the provider and transfusion service, and following the reaction protocol while supporting airway and breathing.
Correct Answer Identify high TACO risk and collaborate on single-unit reassessment, use the ordered controlled rate with close monitoring, and stop and escalate if overload cues develop.
Why It Fits Reducing volume exposure and infusion rate and reassessing before additional blood can reduce circulatory stress in a susceptible client.
Clinical Picture The nurse does not cancel or rewrite the order independently; risk findings are communicated so the prescribed plan can be made safer.
Memory Link Risk, rate, reassess; if breathing worsens, stop and escalate.
NCLEX Rule For a transfusion reaction, stop the transfusion first while supporting ABCs and activating the required protocol.
Why the Alternatives Fail Giving both units rapidly increases volume stress. Waiting for severe respiratory failure delays response. Lowering the head of bed worsens breathing, and assuming every reaction is allergy can miss circulatory overload.
Source
1AABB Association Bulletin 15-02 TACO Revised March 2026
2AABB Association Bulletins
32026 NCLEX-RN Test Plan
The client has multiple TACO risk factors. The nurse follows the blood-administration policy and collaborates with the prescriber and transfusion service rather than independently changing the prescription.
TACO — Transfusion-associated circulatory overload, a reaction caused by fluid volume exceeding the recipient's circulatory tolerance.
Single-Unit Reassessment — Giving one red-cell unit and evaluating clinical and laboratory response before deciding whether another unit is needed.
Transfusion Reaction Protocol — The facility process for stopping blood, supporting the client, notifying responsible services, and completing required checks and specimens.