The nurse is assessing the client during the transfusion of O positive packed red blood cells (PRBCs) that began 15 minutes ago. The client complains of a headache and chills. Current vital signs: Blood pressure 111/58, Heart Rate 106, Respirations 22, and Temperature 100.9F. What action(s) will the nurse take at this time? (Select all that apply).

Choice A rationale Calling the healthcare provider is a necessary step once the transfusion has been stopped and the client is stabilized. The provider needs to be informed of the adverse reaction to order appropriate medications, such as antipyretics, antihistamines, or corticosteroids, and to determine the next steps for the client's care. Timely notification ensures that the medical team can manage potential complications like acute hemolytic reactions or febrile non-hemolytic transfusion reactions effectively. Choice B rationale Stopping the transfusion is the immediate priority action when any sign of a transfusion reaction occurs, such as chills, headache, or a temperature increase. Normal temperature is approximately 98.6 F, and the client's rise to 100.9 F indicates a significant febrile response. Discontinuing the blood flow prevents further exposure to the potentially incompatible or contaminated product, which is essential to protect the client from worsening symptoms or life-threatening systemic complications. Choice C rationale Monitoring vital signs is critical to assess the client's hemodynamic stability and the progression of the reaction. The client is currently tachycardic with a heart rate of 106 beats per minute and tachypneic with 22 breaths per minute. Continuous assessment of blood pressure, heart rate, and temperature allows the nurse to detect signs of shock or escalating systemic inflammation early, providing vital data for the healthcare provider to guide subsequent emergency treatments. Choice D rationale Returning all tubing and blood products to the blood bank is a standard protocol for investigating transfusion reactions. The laboratory must perform a clerical check and various tests, such as a direct antiglobulin test, to identify the cause of the reaction, such as ABO incompatibility or bacterial contamination. This process is vital for documenting the event, ensuring future transfusion safety, and determining if other blood units from the same donor are compromised. Choice E rationale Flushing the current IV tubing with 0.9 percent normal saline is contraindicated because it would push the remaining blood in the tubing into the client's circulation. If a reaction is suspected, the nurse should disconnect the blood tubing at the hub of the catheter and initiate a new infusion of normal saline using completely new tubing. This keeps the vein patent for emergency medications without further exposing the client to the reacting blood product.