# Place the nursing actions in order after a client receiving a red-blood-cell transfusion develops acute dyspnea, crackles, and an oxygen saturation of 86%.

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=568358&lang=en  
> language: en  
> subject: Complications of Procedures  
> category: ROR

## Question

Place the nursing actions in order after a client receiving a red-blood-cell transfusion develops acute dyspnea, crackles, and an oxygen saturation of 86%.

Apply oxygen via nasal cannula and elevate the head of the bed to high Fowler's position.

Obtain a full set of vital signs and prepare for a stat chest X-ray as ordered.

Return the blood product and tubing to the blood bank with a transfusion reaction report.

Stop the transfusion and disconnect the blood tubing from the IV catheter.

Notify the healthcare provider of the client's condition and suspected transfusion reaction.

## Explanation

The client is showing signs of fluid overload during a transfusion. The nurse must first stop the transfusion to prevent further volume, then assess and support oxygenation, notify the provider, and document the event while preserving the blood product for investigation.

## In-depth explanation

Quick answer
Stop the transfusion, then apply oxygen and elevate the head of the bed, then notify the provider, then obtain vital signs and a chest X-ray order, then return the blood product to the blood bank.

Why this is correct
The priority is to stop the infusion causing the overload. Oxygen and positioning address hypoxemia. The provider must be notified to direct further treatment. Vital signs and diagnostic tests help confirm TACO. The blood product is returned after the client is stabilized and the reaction is documented.

Clinical picture
TACO is a transfusion reaction characterized by acute respiratory distress, crackles, hypertension, and hypoxemia due to volume overload. Immediate management includes stopping the transfusion, sitting the client upright, administering oxygen, and notifying the provider. Diuretics may be ordered. The blood product and tubing are sent to the blood bank for investigation.

Memory hook
In any transfusion reaction, the first step is always to stop the transfusion. Then assess and support ABCs, notify the provider, and preserve the product for investigation.

NCLEX decision rule
Prioritize airway, breathing, and circulation. Stop the source of the problem before further assessment or intervention.

Why the alternatives are wrong
Applying oxygen before stopping the transfusion would allow continued fluid administration and worsen overload. Notifying the provider before stopping the transfusion delays critical intervention. Returning the blood product before stabilizing the client is unsafe.

Sources
1NCSBN 2026 NCLEX-RN Test Plan
2Transfusion: bedside patient and blood-product compatibility verification
3NCSBN 2026 NCLEX-RN Test Plan

## Clinical scenario

Transfusion reaction with respiratory distress
A client is 30 minutes into a red-blood-cell transfusion. The nurse notes the client is restless, with new crackles in the lung bases, a respiratory rate of 28 breaths/min, and an oxygen saturation of 86% on room air. The transfusion pump is running at 150 mL/hr. The client's baseline oxygen saturation was 96%.

## Key concepts

- **Transfusion-associated circulatory overload (TACO)** — A transfusion reaction caused by rapid or excessive blood product volume leading to pulmonary edema, dyspnea, crackles, and hypoxemia.
- **Crackles** — Discontinuous, popping lung sounds heard on inspiration, often indicating fluid in the alveoli, as in pulmonary edema.
- **Oxygen saturation** — The percentage of hemoglobin saturated with oxygen; normal is 95-100% on room air. A drop to 86% indicates significant hypoxemia.

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