A nurse is caring for a client. Which findings at 1015 requires further action? (Select all that apply.)

Rationale: A. The client voided brown-colored urine shortly after starting a blood transfusion, which is a sign of hemolysis or a hemolytic transfusion reaction. This requires immediate intervention, including stopping the transfusion and notifying the provider. B. New-onset low back pain during a transfusion is a classic early sign of a hemolytic transfusion reaction. This symptom warrants urgent assessment and action. C. While the respiratory rate increased slightly (from 20 to 28), it is not as immediately dangerous as the hypotension and hemolysis signs. It should be monitored, but it does not require the same urgent action as A, B, and D. D. The client’s blood pressure dropped from 106/56 mm Hg to 74/50 mm Hg, indicating hypotension and possible shock related to a transfusion reaction. This is a life-threatening change that requires immediate action. E. Oxygen saturation decreased minimally (96% to 95%), which is not critically concerning at this time and does not require immediate intervention in the context of this transfusion reaction.