A 78-year-old client with heart failure (ejection fraction 35%) is receiving a second unit of packed red blood cells. Ninety minutes into the unit, the client reports shortness of breath. Findings: SpO2 88% on room air (97% before the transfusion), BP 168/94 mm Hg (138/80 before), HR 112/min, temperature 37.4 C (37.0 C before), crackles in both lower lobes, and distended neck veins. There is no rash or itching. Which actions should the nurse take? Select all that apply.

Quick answer
Options 5, 6, and 4: stop the unit and keep the vein open, position upright with oxygen, and prepare IV furosemide.

Why this is correct
Every suspected reaction starts with stopping the transfusion and keeping IV access with 0.9% saline at a minimal rate. The pattern here is hydrostatic overload: BP rose from 138/80 to 168/94, neck veins are distended, crackles are present, and the client has a low ejection fraction and is on a second unit. Upright positioning, oxygen for SpO2 88%, and a loop diuretic treat the excess volume.

Easy analogy or mental picture
TACO is a bathtub overflowing from the tap (pressure high, veins full); TRALI is a leaky roof with normal plumbing (pressure low or normal, fever, no volume excess).

Memory hook
Pressure UP + veins FULL = TACO: stop, sit up, O2, diurese. Pressure DOWN + fever = think TRALI or hemolysis.

NCLEX decision rule
In transfusion reactions, stop first, then let blood pressure, venous filling, temperature change, and skin findings separate the near-neighbour reactions before choosing treatment.

Why the other choices are wrong
Diphenhydramine and restarting (option 1): appropriate only for mild urticarial reactions; this client has no rash or itching and has respiratory compromise, which never allows the unit to resume. Saline bolus (option 2): tempting because fluids support perfusion in hemolytic reactions or hypotensive TRALI, but this client is hypertensive with fluid overload, so a bolus worsens pulmonary edema. Acetaminophen and resuming (option 3): matches FNHTR, but the temperature rose only 0.4 C (FNHTR requires 1 C or more) and the problem is respiratory; slowing the rate does not treat existing overload.