A nurse is assisting with the care of a postoperative client who is receiving a unit of packed RBCs. Which data should the nurse recognize as an indication of a septic reaction to the blood transfusion?

Choice a: Placing the client in high-Fowler's position is the first action that the nurse should take because it can improve lung expansion and oxygenation, which are priority needs for a client who has a pulmonary embolism and is experiencing dyspnea.

Choice b is not correct because administering heparin to the client is not the first action that the nurse should take, but rather a subsequent action after ensuring adequate oxygenation. Heparin can prevent further clot formation and reduce the risk of complications, but it does not dissolve existing clots or improve respiratory status.

Choice c is not correct because encouraging the client to cough and deep breathe is not the first action that the nurse should take, but rather an ongoing intervention that can help mobilize secretions and prevent atelectasis. However, it may not be effective or feasible for a client who has severe dyspnea.

Choice d is not correct because obtaining the client's vital signs is not the first action that the nurse should take, but rather an assessment that can provide baseline data and monitor changes in condition. However, it does not address the immediate problem of impaired gas exchange or relieve dyspnea.

Choice A: This is correct because suction equipment is essential for clearing the airway of secretions or vomitus during or after a seizure. The nurse should have suction equipment ready and accessible at the client's bedside at all times.

Choice B: This is incorrect because backboard is not needed for a client who has a seizure disorder. Backboard is used for immobilizing the spine in case of a suspected spinal injury.

Choice C: This is incorrect because padded tongue blades are not recommended for a client who has a seizure disorder. Padded tongue blades can cause injury to the teeth, gums, or tongue if inserted during a seizure. The nurse should never force anything into the mouth of a client who is having a seizure.

Choice D: This is incorrect because wrist restraints are not indicated for a client who has a seizure disorder. Wrist restraints can cause injury or skin breakdown if applied during a seizure. The nurse should never restrain or restrict the movements of a client who is having a seizure.