Difficulty: Medium
Average Score: 94%
Full-length
The nurse is caring for a 70-year-old client with hypovolemia who is receiving a blood transfusion. Assessment findings reveal crackles on chest auscultation and distended neck veins. What is the nurse's initial action?
Correct answer
A
Rationale
Crackles and distended neck veins suggest fluid overload from the transfusion. Slowing the transfusion prevents worsening overload. Stopping it (C) is premature, documenting only (B) delays intervention, and pupil assessment (D) is irrelevant.