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: This is correct because placing electrical cords against the wall can prevent tripping and falling, which can cause injury or dislocation of the hip prosthesis. The nurse should instruct the client to remove any clutter or obstacles from the floor and use assistive devices such as a walker or cane.

Choice B: This is incorrect because placing a throw rug next to the bathtub can increase the risk of slipping and falling, especially when the floor is wet. The nurse should instruct the client to avoid using throw rugs or mats and install grab bars and non-skid mats in the bathroom.

Choice C: This is incorrect because keeping pot handles turned toward the edge of the stove can cause burns or spills, which can also lead to falls or infections. The nurse should instruct the client to turn pot handles inward or use the back burners of the stove.

Choice D: This is incorrect because storing extra blankets in a box on the steps can obstruct the access to the stairs and pose a hazard for falling. The nurse should instruct the client to store extra blankets in a closet or drawer and use handrails when using the stairs.

Choice A reason: Chest x-ray showing cardiomegaly is not a new finding for the client who has heart failure, as it indicates enlargement of the heart due to increased workload and pressure on the cardiac chambers.

Choice B reason: PaCO2 55 mmHg is an abnormal finding for the client who has heart failure, as it indicates respiratory acidosis, which is a condition where the lungs cannot eliminate enough carbon dioxide and the blood becomes too acidic. This can be caused by pulmonary edema, which is a complication of heart failure that impairs gas exchange and ventilation.

Choice C reason: Potassium level 4.5 mEq/L is a normal finding for the client who has heart failure, as it indicates adequate electrolyte balance and renal function.

Choice D reason: Urinary output of 1,000 mL in 12 hr is a normal finding for the client who has heart failure, as it indicates adequate fluid status and cardiac output.