Difficulty: Medium
Average Score: 87%
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 reduces further overload while maintaining access. Stopping it entirely or documenting only delays intervention.