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. Move items in the room away from the client: During a seizure, the client may have uncontrolled movements that could cause them to hit nearby objects and potentially injure themselves. Moving items away from the client helps create a safer environment and reduces the risk of injury from contact with objects.

B. Loosen the client's clothing: Seizures can lead to muscle contractions and movements that might constrict the client's clothing, particularly around the neck or chest area. Loosening the client's clothing helps ensure that their breathing is not restricted during the seizure.

C. Turn the client onto their side: Turning the client onto their side is an important step for airway protection. During a seizure, there is a risk of saliva or vomit obstructing the airway, which can lead to aspiration. Turning the client onto their side helps prevent aspiration by allowing any fluids to drain out safely and maintaining an open airway.

D. Help the client lie on the floor: If the client is seated in a chair during a seizure, it's safer to assist them in lying on the floor. This action prevents the client from falling out of the chair and potentially sustaining injuries from the fall. Once on the floor, the nurse can continue to monitor the client and provide appropriate care and support.

A. The client adjusts the head of their bed to 90°: Adjusting the head of the bed to 90° is a correct action for clients with dysphagia as it helps facilitate swallowing by promoting an upright position, reducing the risk of aspiration.

B. The client drinks their thickened juice with a straw.

Drinking thickened liquids with a straw is not recommended for clients with dysphagia. Straws can increase the risk of aspiration, as they bypass the natural protection mechanisms in the mouth and throat that help prevent liquids from entering the airway. Therefore, the nurse should intervene and provide the client with an appropriate drinking cup instead of a straw when consuming thickened liquids.

C. The client tucks their chin when they swallow: Tucking the chin when swallowing is a recommended technique for clients with dysphagia, as it helps close off the airway and directs the food or liquid toward the esophagus, reducing the risk of aspiration.

D. The client takes frequent breaks while eating: Taking frequent breaks while eating is a beneficial strategy for clients with dysphagia, as it allows them to rest and swallow safely without feeling rushed or overwhelmed by large amounts of food or liquid.