NCLEX Question of the Day – Saturday, April 18, 2026

Today’s question focuses on priority nursing action in a common Med-Surg situation: recognizing early signs of fluid overload during a blood transfusion. This matters in real nursing because bedside changes can happen fast, and the nurse often catches the problem first. Knowing what to do immediately helps protect the patient’s airway, breathing, and circulation while preventing the complication from getting worse.

Clinical Scenario

A 76-year-old adult is admitted to a medical-surgical unit for symptomatic anemia after several days of black, tarry stools. The patient has a history of heart failure with reduced ejection fraction, chronic kidney disease, and hypertension. A provider prescribes 1 unit of packed red blood cells. The transfusion begins 20 minutes ago.

Before the transfusion, the patient’s lungs were clear, oxygen saturation was 96% on room air, and blood pressure was 138/76 mm Hg. Now the patient says, “I feel short of breath.” The nurse notes new crackles at the lung bases, a frequent cough, jugular vein distention, and oxygen saturation of 90% on room air. Temperature is unchanged from baseline.

The Question

What is the nurse’s priority action?

Answer Choices

1. A. Slow the transfusion rate and reassess breath sounds in 15 minutes
2. B. Stop the transfusion, place the patient upright, and notify the provider and blood bank
3. C. Administer prescribed acetaminophen and continue monitoring for fever
4. D. Flush the IV line with the remaining blood product to maintain venous access

Correct Answer

B. Stop the transfusion, place the patient upright, and notify the provider and blood bank

Detailed Rationale

This patient is showing signs of transfusion-associated circulatory overload, often called TACO. The key clues are new shortness of breath, crackles, jugular vein distention, cough, and falling oxygen saturation during a transfusion. The unchanged temperature matters because it makes a febrile reaction less likely. The history also matters: heart failure and kidney disease increase the risk because the body may not handle the added volume well.

The nurse’s first job is to stop the transfusion. That prevents more volume from entering the circulation. In NCLEX questions, when a patient develops respiratory symptoms during blood administration, the safest immediate step is to stop the blood unless the stem clearly points to a harmless issue. Here, the patient is getting worse, not better.

Next, the nurse should position the patient upright. High-Fowler’s or sitting upright helps lung expansion and reduces the work of breathing. This is practical bedside care, not just a test answer. A patient with fluid backing up into the lungs often breathes easier when upright.

Then the nurse should assess and support oxygenation. That includes checking full vital signs, listening to lung sounds, applying oxygen if needed per facility protocol or prescription, and monitoring pulse oximetry. The nurse should also ensure the IV line stays patent according to transfusion policy, usually with new tubing and normal saline if ordered or required by protocol, not with blood product.

The nurse must also notify the provider and the blood bank. The provider may prescribe a diuretic, order a chest assessment, or adjust future transfusions to run more slowly or in divided units. The blood bank should be informed because any suspected transfusion reaction requires follow-up and documentation. Even when the cause appears to be volume overload rather than hemolysis, the event still needs proper reporting.

Ongoing monitoring is important because the nurse needs to see whether the patient improves or deteriorates. Watch for worsening hypoxia, increased crackles, frothy sputum, rising blood pressure, tachycardia, and escalating respiratory distress. Also reassess intake and output, since poor urine output can support the concern for fluid retention.

The deeper nursing point is this: pattern recognition matters. Fever, chills, flank pain, or hypotension would push you toward other transfusion reactions. But this pattern points to too much circulating volume reaching a patient who cannot tolerate it well. In practice, your rapid recognition changes outcomes.

Why the Other Options Are Wrong

A. Slow the transfusion rate and reassess breath sounds in 15 minutes

This is unsafe because the patient already has signs of overload. Slowing the rate still gives more blood volume to a patient who is not tolerating it. When respiratory symptoms begin during transfusion, the nurse should not wait to see if they pass.

C. Administer prescribed acetaminophen and continue monitoring for fever

Acetaminophen may be used for fever or mild discomfort, but fever is not the issue here. This option focuses on the wrong problem and delays urgent intervention for impaired breathing and excess fluid volume.

D. Flush the IV line with the remaining blood product to maintain venous access

This is incorrect and dangerous. The nurse should never flush in more blood when a transfusion reaction or complication is suspected. That would increase exposure to the product and make the problem worse.

Key Takeaways

• New dyspnea, crackles, JVD, cough, and lower oxygen saturation during transfusion strongly suggest circulatory overload.
• Patients with heart failure, kidney disease, older age, or rapid transfusion are at higher risk.
• The priority action is to stop the transfusion immediately.
• Position the patient upright and assess oxygenation right away.
• Notify the provider and blood bank, then continue close monitoring and documentation.

• What you’d do on shift: Stop the blood, sit the patient up, get full vital signs, check lung sounds and oxygen saturation, apply oxygen as needed, keep IV access per policy, call the provider and blood bank, and prepare for likely orders such as a diuretic.

Quick Practice Extension

1. A patient develops fever, chills, and low back pain 10 minutes after a transfusion starts. What assessment findings would make you suspect an acute hemolytic reaction instead of circulatory overload?
2. A patient with heart failure needs 2 units of packed red blood cells. What nursing actions before and during the transfusion could reduce the risk of volume-related complications?

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