A nurse is caring for a client Based on the client's symptoms and vital signs, which nursing actions are appropriate? (Select all that apply.)

Rationale: A. The client has a fever (38.3°C/100.9°F) and chills, which are indicative of a febrile non-hemolytic transfusion reaction, the most common transfusion reaction. Antipyretics like acetaminophen are appropriate for symptom management. B. IV fluids are important to maintain venous access and support blood pressure during a transfusion reaction. Normal saline can also help flush the IV line and prepare for potential complications. C. Immediate discontinuation of the blood transfusion is the first priority whenever a transfusion reaction is suspected. Continuing the transfusion can worsen the reaction. D. Diuretics are not indicated in this scenario. They are used for circulatory overload (TACO), which presents with dyspnea, hypertension, and pulmonary edema, not chills and fever. E. The blood product and tubing should be sent to the lab for investigation of a possible hemolytic or bacterial reaction. This is a required step for all suspected transfusion reactions. F. Antihistamines are indicated for allergic transfusion reactions, which present with rash, itching, or hives. This client’s symptoms are not consistent with an allergic reaction, so an antihistamine is not immediately required.