# 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. > source: MyMerci (mymerci.kr) > url: https://mymerci.kr/pages/nclex_q.php?qn_id=617285&lang=en > language: en > subject: Complications of Procedures > category: ROR ## Question 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. 1 Give diphenhydramine and restart the unit when breathing eases. 2 Infuse a 500 mL 0.9% sodium chloride bolus to protect kidney perfusion. 3 Give acetaminophen and resume the unit at half the previous rate. 4 Prepare to give IV furosemide as prescribed by the provider. 5 Stop the unit and keep the IV line open with 0.9% sodium chloride. 6 Sit the client upright and apply oxygen to keep SpO2 at 92% or above. ## Explanation Hypertension, distended neck veins, crackles, and hypoxemia in a client with reduced ejection fraction during a second unit indicate TACO. The nurse stops the unit while keeping the line open at a keep-vein-open rate, sits the client up with oxygen, and prepares a diuretic. Diphenhydramine treats an allergic reaction, a saline bolus fits a hypotensive hemolytic or TRALI picture, and acetaminophen with resumption treats FNHTR, which requires a rise of at least 1 C. ## In-depth explanation 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. References 1CDC NHSN Hemovigilance Module ProtocolCase definitions distinguishing TACO, TRALI, FNHTR, allergic, and hemolytic transfusion reactions 2AABB (Association for the Advancement of Blood & Biotherapies)Stopping the transfusion and managing suspected transfusion reactions ## Clinical scenario Scenario An older adult with heart failure develops dyspnea, hypoxemia, hypertension, crackles, and distended neck veins 90 minutes into a second unit of red blood cells, with only a slight temperature rise and no rash. ## Key concepts - **Transfusion-associated circulatory overload** — Hydrostatic pulmonary edema from transfused volume, with hypertension and distended neck veins, typically in clients with cardiac or renal disease. - **Transfusion-related acute lung injury** — Non-cardiogenic pulmonary edema within 6 hours of transfusion, often with fever and hypotension and without volume overload. - **Febrile non-hemolytic transfusion reaction** — A temperature rise of at least 1 C, with or without chills, without hemolysis or respiratory compromise. ## Related questions - [A nurse cares for a client 12 hours after thoracotomy with a chest tube connected to a wet…](https://mymerci.kr/pages/nclex_q.php?qn_id=366310&lang=en) - [A nurse is caring for a 64-year-old client 2 hours after a diagnostic cardiac catheterizat…](https://mymerci.kr/pages/nclex_q.php?qn_id=368186&lang=en) - [A patient on mechanical ventilation has bilateral infiltrates on chest x-ray, no signs of …](https://mymerci.kr/pages/nclex_q.php?qn_id=372717&lang=en) - [A 38-week newborn is delivered limp, apneic, and cyanotic. 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