A nurse is assessing a client who is receiving a blood transfusion. The nurse notes lung crackles, hypoxia, and distended neck veins. Which of the following actions should the nurse take? (Select all that apply.)

A. Adjusting the oxygen flow rate as needed is incorrect because oxygen is a prescribed medical gas. The client or caregiver must never alter the flow rate based on subjective breathing comfort; it should only be adjusted under the explicit direction of the healthcare provider.

B. Antibiotic therapy should be taken for 10 days is an incorrect assumption. The client’s cefazolin IV was discontinued on Day 4, and the provided chart details do not show an ongoing oral antibiotic prescription intended for home use.

C. Storing the oxygen cylinder wrench with the oxygen tank is a critical safety practice. This ensures that the specialized wrench needed to quickly turn the tank valve on or off is immediately accessible to the client or caregiver during an emergency or tank change.

D. Ensuring the oxygen delivery system is at least 8 feet from any heat source is an essential home fire-safety measure. Oxygen strongly accelerates combustion, so keeping tanks and tubing far away from sources like stoves, space heaters, or open flames prevents accidental fires.

E. Steroid medication should be taken in the morning because systemic corticosteroids can cause significant insomnia and central nervous system stimulation if taken later in the day. A morning dose also closely mimics the body's natural diurnal rhythm of cortisol release.

F. Antibiotic medication can be taken with or without food is incorrect because the client's current IV antibiotic therapy was discontinued, and there is no active prescription for a home oral antibiotic listed in the medical records to teach about.

G. The steroid dose will decrease each day is incorrect based on the medical records. The client is prescribed a steady dose of prednisone 40 mg daily, and there is no indication or instruction in the MAR for a daily tapering schedule at this time.

A. Placing the client in high Fowler's position helps improve lung expansion and oxygenation.
B. Administering oxygen helps address hypoxia and supports adequate oxygenation.
C. Stopping the transfusion is crucial when signs of a transfusion reaction are present.
D. Administering a diuretic is not typically indicated for transfusion reactions involving lung crackles, hypoxia, and distended neck veins.
E. Epinephrine is not typically used to manage a blood transfusion reaction; it's more for severe allergic reactions like anaphylaxis.