A nurse is assisting with the care of a client who is receiving a blood transfusion. The nurse should monitor for which of the following findings as an indication the client is having an acute hemolytic reaction?

Choice A reason: Notifying the physician is important, but it is not the immediate action to take. The nurse should first assess the patient's condition before contacting the physician.

Choice B reason: Evaluating the distal pulses is the correct action because it provides information on the blood flow to the extremities, which is crucial for patients with PAD.

Choice C reason: Having the patient lie in bed with a pillow under the knees is not recommended for PAD patients as it can decrease blood flow to the lower extremities.

Choice D reason: Covering the patient with a blanket may provide comfort, but it does not address the underlying issue of impaired blood flow in PAD.

Choice A: "I’m sorry if I upset you. I just wanted to make sure you’re aware of the day’s schedule."

This response may seem empathetic, but it could potentially reinforce the client's aggressive behavior. The nurse is apologizing, which might give the impression that the client's rude behavior is acceptable¹.

Choice B: "Well, if you can read it yourself, then why don’t you?"

This response is confrontational and could escalate the situation. It's important for the nurse to maintain a neutral and respectful manner.

Choice C: "You don’t have to be so rude. I’m just doing my job."

This response is defensive and could provoke further aggression from the client. It's not recommended to respond defensively to clients with borderline personality disorder¹.

Choice D: "I didn’t mean to offend you. I’ll leave the schedule here for you to review."

This is the most appropriate response. The nurse acknowledges the client's feelings without reinforcing the aggressive behavior. The nurse also respects the client's autonomy by leaving the schedule for the client to review¹.