When changing the client's dressing for a vacuum-assisted closure (VAC) wound therapy system, the nurse observes foul, purulent drainage.
Which intervention(s) should the nurse implement? Select all that apply.

Choice A rationale

Stopping the blood transfusion is critical to prevent the progression of a transfusion reaction, which can be life-threatening. Immediate cessation of the transfusion minimizes the amount of incompatible blood entering the patient’s system, reducing the risk of serious complications such as hemolysis or anaphylaxis. Rapid intervention is necessary to ensure the patient’s safety and to provide time for assessment and implementation of appropriate treatments. Recognizing the signs of a transfusion reaction and acting swiftly is essential in managing the patient’s condition effectively.

Choice B rationale

Administering an antipyretic is not the priority action when a transfusion reaction is suspected. Fever can be a symptom of a transfusion reaction, but stopping the transfusion and assessing the patient are more urgent. Antipyretics like acetaminophen can be given to manage fever, but only after the transfusion is halted and the patient’s overall condition has been evaluated. Addressing the root cause of the reaction takes precedence to prevent further complications.

Choice C rationale

Encouraging oral fluids is not an immediate priority during a transfusion reaction. While maintaining hydration is important, the initial step must be to stop the transfusion and assess the patient’s condition. Oral fluids do not address the underlying issue of the transfusion reaction and are not effective in managing acute symptoms. Prioritizing actions that directly mitigate the reaction is essential for patient safety.

Choice D rationale

Applying supplemental oxygen may be necessary if the patient exhibits signs of respiratory distress during a transfusion reaction. However, the first action should be to stop the transfusion to prevent further exposure to the incompatible blood product. Oxygen can be administered as a supportive measure after the transfusion is halted and the patient’s respiratory status is assessed. Addressing the immediate cause of the reaction is paramount.

Choice E rationale

Sending blood for type and crossmatch is important for identifying the cause of the transfusion reaction and ensuring safe future transfusions. However, this action is not the priority during the acute phase of a reaction. Stopping the transfusion and assessing the patient’s condition must come first to stabilize the patient and prevent further complications. Laboratory testing can be performed once the patient’s immediate needs are addressed.

Choice A rationale

Assisting the client to void before walking can prevent potential incontinence episodes, which might be embarrassing for the client. Additionally, a full bladder can increase the risk of falls due to discomfort or urgency to get to the restroom quickly.

Choice B rationale

While instructing the client about signs of orthostatic hypotension is important, it is not within the scope of practice for an unlicensed assistive personnel (UAP) to provide such instructions. This task falls under the responsibility of a licensed nurse.

Choice C rationale

Measuring the client's vital signs before walking helps to assess the client's baseline status and ensures that the client is stable enough to engage in physical activity. Any abnormal readings could indicate the need to postpone or modify the activity.

Choice D rationale

Reporting the onset of any dizziness or light-headedness is crucial for ensuring the client's safety during activity. These symptoms could indicate underlying issues such as orthostatic hypotension or other cardiovascular problems that need to be addressed promptly.

Choice E rationale

Determining if a gait belt is needed ensures that the client receives appropriate support while walking. A gait belt can provide additional stability and help prevent falls, especially for clients with limited tolerance for activity.