The older adult client is receiving the third unit of packed red blood cells that have been administered in the last 8 hours. One hour into the third transfusion, a nurse observes the client to have distended neck veins in the sitting position
What is the nurse's best first ac-tion? A. Slow the infusion rate.
B. Discontinue the transfusion.
C. Document the observation as the only action.
D. Check the type of infusing blood with the client's blood type.
A
Older adult clients are at risk for developing fluid overload during transfusion therapy, especially when receiving multiple units of packed red blood cells, which have a high osmotic pressure. The infusion rate should be slowed as low as possible, even before the client's circulatory status is assessed, to prevent worsening of the problem.
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