A 79-year-old client with heart failure (ejection fraction 30%) is receiving a second unit of packed red blood cells for a hemoglobin of 7.1 g/dL. The client also received 1,500 mL of IV fluid over the previous 12 hours. Thirty minutes after the second unit starts, the client becomes short of breath and sits upright. Pretransfusion vital signs: temperature 36.9°C, blood pressure 138/74 mm Hg, heart rate 84/min, oxygen saturation 95%. Current: temperature 37.0°C, blood pressure 178/92 mm Hg, heart rate 112/min, respiratory rate 30/min, oxygen saturation 88% on room air. Bilateral crackles and distended neck veins are present. The skin has no hives, the client denies back pain, and urine is pale yellow. Complete the diagram by selecting the condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.

Quick answer
Transfusion-associated circulatory overload (TACO). Stop the transfusion, keep the IV line open, sit the client upright, and give oxygen. Monitor oxygen saturation and lung sounds for crackles.

Why this is correct
TACO and TRALI both cause sudden hypoxemia and crackles during transfusion. Here the blood pressure rose from 138/74 to 178/92, the neck veins are distended, the temperature did not change, and the client has heart failure plus 1,500 mL of recent IV fluid. These are signs of volume overload. Stopping the unit removes the volume source, keeping the line open preserves access for a prescribed diuretic, and upright positioning with oxygen improves gas exchange. Saturation and crackles show whether pulmonary congestion is clearing.

Easy analogy or mental picture
Picture a small bucket already full to the brim: adding another unit makes it spill into the lungs. You turn off the tap, not just slow it.

Memory hook
TACO = Too much volume: high BP, big neck veins, wet lungs. TRALI = low BP and fever.

NCLEX decision rule
When a transfusion reaction threatens breathing, stop the unit first, keep the line open, support oxygenation, and then use the blood pressure, temperature, and history to identify the reaction.

Why the other choices are wrong
Slowing the rate is sometimes taught for mild overload, but a saturation of 88% calls for stopping the unit. Diphenhydramine and checking the skin for hives fit an allergic reaction, and no hives are present. A saline bolus treats the hypotension of hemolytic reactions or TRALI and would add to this overload. Serial temperatures fit a febrile nonhemolytic reaction, and urine color tracks hemolysis; this client is afebrile with pale yellow urine and no back pain.