A nurse is conducting a postoperative assessment on a client in a surgical ward

Complete the diagram by dragging from the choices below to specify 1 potential condition the client is most likely experiencing, 2 actions the nurse would take to address that condition, and 2 parameters the nurse would monitor to assess the client's progress.

Rationale:

A. AB- blood contains both A and B antigens on the red blood cells. A recipient with blood type A- has anti-B antibodies in their plasma. If AB- blood is transfused, the recipient’s immune system will recognize the B antigens as foreign, leading to a potentially dangerous hemolytic reaction.

B. While A+ blood has the A antigen that matches the recipient’s ABO type, it is Rh-positive, and the recipient is Rh-negative (A-). Transfusing Rh-positive blood to an Rh-negative individual can trigger alloimmunization, where the immune system develops antibodies against the Rh factor. This is especially concerning in women of childbearing age, as it may affect future pregnancies, and it can also cause hemolytic transfusion reactions.

C. O- blood has no A or B antigens and is Rh-negative, making it the universal donor for red blood cells. An A- recipient will not react immunologically to O- red blood cells because there are no antigens to trigger an antibody response. O- blood is safe for emergency transfusions when a perfectly matched unit is unavailable.

D. AB+ blood contains A and B antigens as well as Rh-positive antigen. Transfusing AB+ to an A- recipient is incompatible because the B antigens would trigger anti-B antibodies and the Rh-positive factor could cause alloimmunization, making this combination unsafe.

E. A- blood is both ABO compatible (A antigen matches) and Rh compatible (negative). This is the ideal match for an A- recipient because it eliminates the risk of immune-mediated hemolysis and ensures safe transfusion.

F. Although O blood lacks A and B antigens, O+ blood contains the Rh D antigen, which is incompatible with an Rh-negative recipient. Transfusing O+ blood to an A- recipient could trigger alloimmunization or hemolytic reaction, so it is unsafe.

Rationale:

A. Acute hemolytic reactions are typically caused by incompatible blood transfusions. They present with fever, chills, hypotension, low back pain, hemoglobinuria, dyspnea, and anxiety. The absence of low back pain, hypotension, or hemoglobinuria makes an acute hemolytic reaction less likely in this scenario.

B. Septic transfusion reactions result from bacterial contamination of the blood product. Symptoms include high fever, chills, hypotension, tachycardia, and shock, often progressing rapidly. The client’s stable hemodynamics and absence of systemic signs of sepsis make this less likely.

C. This is the most common type of transfusion reaction and is typically caused by antibodies to donor leukocytes. It presents with shaking chills, fever, and muscle stiffness, usually without hypotension, dyspnea, or hemoglobinuria. The reaction often occurs within the first 30–90 minutes of transfusion, matching this client’s presentation.

D. Allergic reactions usually involve urticaria, pruritus, flushing, and sometimes angioedema. Fever and muscle stiffness are not typical, so this client’s symptoms are inconsistent with an allergic reaction.