Which of the following actions should the nurse take immediately?
(Select the 4 actions the nurse should take.)

Exhibits

Rationale:

Stop transfusion: The client is showing signs of a serious transfusion reaction such as fever, chills, back pain, and hypotension. Immediately stopping the transfusion prevents further infusion of incompatible blood, which could worsen hemolysis and lead to shock or kidney failure.

Flush blood transfusion tubing: Flushing the existing blood tubing with saline could push more incompatible blood cells into the circulation. This can intensify the reaction and increase the risk of complications. Instead, new IV tubing with normal saline should be used if further IV access is needed.

Notify blood bank: The blood bank must be informed to initiate an investigation, verify blood compatibility, and conduct testing to determine the cause of the reaction. This helps prevent further occurrences and ensures patient safety.

Notify primary physician: The physician needs to be informed promptly to provide additional orders, such as fluid resuscitation, lab tests, or medications to stabilize the client. Immediate collaboration is essential to manage the adverse event effectively.

Return blood and tubing to blood bank: Returning the blood product and used tubing allows the blood bank to analyze the unit for errors or contamination. This is necessary for confirming the transfusion reaction and documenting the incident.

Administer IV diphenhydramine: Diphenhydramine may be used to reduce symptoms such as itching or chills if an allergic component is suspected. It is often part of the initial response while further evaluation and treatment are underway.

Administer oxygen: The client’s oxygen saturation has dropped, and respirations are rapid and labored. Administering oxygen supports tissue oxygenation and addresses hypoxia during this acute reaction, which may compromise respiratory function.

Rationale:
A. Notify the surgeon of the temperature elevation: While the surgeon may need to be informed if there are signs of infection or persistent fever, the nurse should first gather more data to determine the possible cause of the elevated temperature.

B. Encourage the client to drink more fluids: Increased fluid intake may help reduce mild postoperative fever, especially if it's related to dehydration or atelectasis. However, this is not the priority without assessing for infection first.

C. Assess the surgical incision for signs of infection: The priority is to assess for potential sources of infection, particularly the surgical site, given that the client is 3 days postoperative and has a fever. Early identification of infection is critical to prevent complications such as wound dehiscence or sepsis.

D. Monitor vital signs every 4 hr: Routine monitoring is important but does not take precedence over immediate assessment of the surgical site when there is a concerning temperature elevation. The nurse should act to identify the cause first.