# 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.

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=617418&lang=en  
> language: en  
> subject: Complications of Procedures  
> category: ROR

## Question

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.

Condition

Select 1
Acute hemolytic reaction to incompatible blood
Transfusion-associated circulatory overload
Transfusion-related acute lung injury
Febrile nonhemolytic transfusion reaction

Actions to take

Select 2
Slow the infusion rate and recheck in 15 minutes
Give prescribed IV diphenhydramine 25 mg
Stop the transfusion and keep the line open
Infuse a 500 mL normal saline bolus
Sit the client upright and apply oxygen

Parameters to monitor

Select 2
Lung sounds for crackles
Temperature every 15 minutes
Urine color for hemoglobinuria
Skin for new urticaria
Oxygen saturation

## Explanation

Hypertension, distended neck veins, and crackles in a client with heart failure and recent fluid loading point to circulatory overload rather than TRALI, which usually brings hypotension and fever. The nurse stops the transfusion, keeps the line open, positions the client upright, and gives oxygen. Slowing the rate is too little with a saturation of 88%, and a saline bolus would worsen the overload.

## In-depth explanation

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.

References
1MedlinePlus: Blood Transfusion and DonationTransfusion reactions and nursing monitoring during transfusion
2CDC NHSN — Hemovigilance Module Surveillance ProtocolCase definitions distinguishing TACO, TRALI, hemolytic, febrile, and allergic reactions

## Clinical scenario

Scenario
An older adult with heart failure and a positive fluid balance develops dyspnea, hypertension, crackles, distended neck veins, and hypoxemia 30 minutes into a second unit of RBCs, without fever, hives, or back pain.

## Key concepts

- **TACO** — Hydrostatic pulmonary edema caused by transfusion volume exceeding the circulation's capacity, usually with hypertension.
- **TRALI** — Noncardiogenic acute lung injury within 6 hours of transfusion, often with fever and hypotension.
- **Jugular venous distention** — Visible distention of the neck veins that reflects elevated right-sided filling pressure.

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