The nurse assesses a client who is receiving a blood transfusion. Assessment findings reveal crackles on chest auscultation and distended neck veins. Which action should the nurse take?

Rationale: A. Crackles and distended neck veins indicate fluid overload, most consistent with transfusion-associated circulatory overload (TACO). This is a serious complication of blood transfusion. The priority action is to stop the transfusion immediately to prevent worsening pulmonary edema and cardiovascular compromise, while maintaining IV access with normal saline. This is the safest and most appropriate intervention. B. Assessing the client’s pupils is unrelated to the current findings. The client is showing signs of fluid overload affecting the respiratory and cardiovascular systems, not neurological impairment. C. Slowing the transfusion is not sufficient in the presence of clear signs of transfusion complications. Continuing the transfusion, even at a slower rate, can worsen the client’s condition. The transfusion must be stopped. D. While documentation is important, it is not the priority action. Immediate intervention to stop the transfusion and stabilize the client takes precedence over recording findings.