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 reason: Passing of flatus is not a reliable indicator of colostomy function, as it can occur even when there is an obstruction or ischemia in the bowel.

Choice B reason: Stoma is pinkish-red is a sign of a healthy and well-perfused colostomy, as it indicates that the blood supply to the bowel segment is adequate and there is no necrosis or infection.

Choice C reason: Tolerating a clear liquid diet is not a specific indicator of colostomy function, as it does not reflect the amount or consistency of the stool output.

Choice D reason: Absent bowel sounds are not a normal finding for a colostomy, as they can indicate a paralytic ileus or a bowel obstruction, which can cause complications such as distension, pain, or perforation.

Choice A: This is incorrect. The client having difficulty reading large print indicates a need for an ophthalmology referral, not an occupational therapy referral. An ophthalmologist can assess and treat vision problems caused by stroke.

Choice B: This is incorrect. The client coughing while drinking from a straw indicates a need for a speech therapy referral, not an occupational therapy referral. A speech therapist can assess and treat swallowing problems caused by stroke.

Choice C: This is incorrect. The client being unable to bear her full weight while walking indicates a need for a physical therapy referral, not an occupational therapy referral. A physical therapist can assess and treat mobility problems caused by stroke.

Choice D: This is correct. The client becoming exhausted while brushing her teeth indicates a need for an occupational therapy referral. An occupational therapist can assess and treat functional problems caused by stroke, such as fatigue, self-care, cognition, and leisure activities.