Free NCLEX RN Practice Questions Practice Question
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: In this scenario, the presence of crackles in the lungs and distended neck veins indicates potential fluid overload, which can occur during a blood transfusion. Slowing the transfusion (Option A) is the appropriate initial action to mitigate further complications while monitoring the client’s response.
Option B, documenting the findings without intervention, neglects the immediate need to address the client's symptoms. Option C, stopping the transfusion and administering normal saline, is a necessary step but should follow the initial action of slowing the transfusion to prevent rapid deterioration. Option D, assessing the client’s pupils, is irrelevant to the immediate respiratory and circulatory concerns and does not address the current situation effectively.
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