An adult client who had a gastric bypass surgery is admitted with possible anastomosis leakage. The client’s abdomen is tender to touch, and the vital signs are: temperature 38.3° C, heart rate 130 beats/minute, respiratory rate 20 breaths/minute, and blood pressure 100/50 mm Hg. Which intervention is most important for the nurse to include in the client’s plan of care?

Choice A rationale
An ABO incompatibility reaction can occur if a patient receives the wrong type of blood during a blood transfusion. Symptoms of an ABO incompatibility reaction include lower back pain and hypotension, which are serious and should be reported immediately to the healthcare provider.
Choice B rationale
A delayed painful rash with urticaria is not typically a symptom of an ABO incompatibility reaction. While it could indicate an allergic reaction, it is not as immediate or potentially life-threatening as the symptoms in Choice A1.
Choice C rationale
Acute rhinitis and nasal stuffiness are more commonly associated with respiratory infections, not ABO incompatibility reactions. These symptoms are not typically a direct result of a blood transfusion.
Choice D rationale
Arthritic joint changes and chronic pain are not associated with ABO incompatibility reactions. These symptoms are more likely related to long-term conditions like arthritis.

Choice A rationale
Applying oxygen at 10 L via non-rebreather mask and monitoring pulse oximeter is the most important intervention for a patient in the post-anesthesia care unit (PACU) with a heart rate of 140 beats/minute, blood pressure 140/90 mm Hg, and respirations 26 breaths/minute.
These vital signs suggest that the patient may be experiencing hypoxia or respiratory distress, conditions that require immediate intervention.
Choice B rationale
Medicating for pain and monitoring vital signs according to protocol is important in the PACU, but it is not the most critical intervention in this scenario. The patient’s vital signs suggest a possible respiratory issue, which should be addressed immediately.
Choice C rationale
Encouraging the client to splint the incision with a pillow to cough and deep breathe is a common postoperative intervention to promote lung expansion and prevent atelectasis and pneumonia. However, in this scenario, the patient’s vital signs suggest a more immediate respiratory issue that requires prompt intervention.
Choice D rationale
Administering an intravenous fluid bolus as prescribed by the healthcare provider can be an appropriate intervention for certain conditions in the PACU, such as hypotension. However, in this scenario, the patient’s vital signs suggest a possible respiratory issue, which should be addressed immediately.