A nurse is monitoring a client who is receiving 2 units of packed RBCs to treat anemia. The nurse should identify which of the following findings is an indication of fluid overload?

This clinical scenario requires the application of transfusion monitoring principles to recognize complications. The nurse must identify physical signs indicating circulatory overload, which occurs when blood volume is infused too rapidly for the cardiovascular system. Choice A rationale Hypervolemia increases venous hydrostatic pressure, which manifests as jugular venous distention when the client is upright. This is a primary sign of transfusion-associated circulatory overload, requiring immediate cessation of the infusion. Choice B rationale Itching is a manifestation of an allergic transfusion reaction, which is mediated by histamine release in response to plasma proteins. It does not indicate volume overload or compromised cardiovascular hemodynamics. Choice C rationale Low back pain is a classic indicator of an acute hemolytic transfusion reaction, resulting from RBC lysis and subsequent renal tubular occlusion. It is not an indicator of fluid volume excess. Choice D rationale Fever indicates a febrile non-hemolytic reaction or a septic transfusion reaction caused by bacterial contamination. It is an immune or inflammatory response to leukocytes or pyrogens, not a sign of hypervolemia..