A nurse is assessing a client who is receiving a blood transfusion. The nurse notes lung crackles, hypoxia, and distended neck veins. Which of the following actions should the nurse take? (Select all that apply.)

B. This is a hallmark sign of anaphylaxis. During an anaphylactic reaction, blood vessels dilate, and fluid can leak out of the bloodstream into surrounding tissues, leading to a sudden drop in blood pressure (hypotension). This is a key indicator of anaphylaxis and requires immediate attention.
A. Anaphylactic reactions typically cause an increase in heart rate (tachycardia) rather than a decrease (bradycardia). The body reacts to the perceived threat by releasing a flood of chemicals, such as histamine, which can cause the heart to pump faster. Therefore, a sudden decrease in heart rate is not characteristic of anaphylaxis.
C. Swelling can occur in various parts of the body during an allergic reaction, but it is more common in areas such as the face, lips, tongue, and throat, which can compromise the airway. Swelling in the feet

alone is less likely to be associated with anaphylaxis and more indicative of localized or less severe reactions.
D. Pain at the injection site is a common local reaction to an IM injection and is not specific to anaphylaxis. While it can be uncomfortable, it is not indicative of a systemic allergic reaction.

C. Gloves should be removed first as they are likely to be the most contaminated, followed by the gown, then eyewear, and finally the mask. This sequence helps ensure that the nurse minimizes the risk of contaminating themselves or the environment.
A. After gloves, the gown should be removed. The gown may have become contaminated during the client care activities, and removing it prevents the spread of any potential pathogens to other areas.
B. Eyewear should be removed after the gown. Eyewear provides protection for the eyes from any splashes or sprays during client care. Removing it last ensures that any potential contaminants on the eyewear do not come into contact with the face or eyes during the removal process.
D. The mask should be removed last because it is considered the least contaminated item since it is worn over the nose and mouth, directly exposed to the client's respiratory secretions.