Practice Question
A nurse is preparing to administer a transfusion of RBCs to a client who has heart failure. For which of the following manifestations should the nurse monitor to prevent fluid volume overload? (Select all that apply.)
Answer Choices:
Correct Answer:
Dyspnea
Rationale:
Dyspnea
🔵Dyspnea is an early, sensitive sign of transfusion-associated circulatory overload (TACO), especially in clients with heart failure.
🔵Excess transfusion volume raises preload and pulmonary venous pressure, causing interstitial and alveolar fluid and resulting in tachypnea, orthopnea, and crackles.
🔵Monitoring for increasing work of breathing, new oxygen needs, or declining SpO₂ helps catch overload before frank pulmonary edema develops.
🔵If dyspnea appears, the nurse should stop or slow the transfusion, place the client upright, apply oxygen, and anticipate IV diuretics per protocol.
Jugular vein distention (JVD)
🔵JVD reflects elevated central venous pressure, a hallmark of volume overload from the added intravascular volume of RBCs.
🔵In heart failure, limited cardiac reserve means even modest volume can back up into the venous system, making JVP rise visible at 30–45°.
🔵Trending JVP (along with S3, hepatomegaly, peripheral edema) provides a hemodynamic window into right-sided strain during transfusion.
🔵Early recognition allows rate reduction, diuretic therapy, and careful I&O to prevent progression to acute decompensation.
Confusion
🔵Acute confusion or agitation signals possible cerebral hypoxia from worsening pulmonary congestion or falling cardiac output.
🔵Older adults with heart failure are particularly vulnerable; subtle mental-status changes may precede obvious respiratory signs.
🔵Continuous assessment of LOC, orientation, and restlessness alongside vitals and SpO₂ can unmask evolving overload.
🔵Prompt action (positioning, oxygen, slowing/stopping transfusion, notifying the provider) can prevent respiratory failure.
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This question is from Custom 2201 Unit 3 Exam 2025 which contains 58 questions.
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Question Details
- Category: RN Nursing Exam(s)
- Subcategory: ATI Exam(s)
- Domain: RN Custom Exam(s)
- Answer Choices: 5