A nurse is assisting with the care of a postoperative client who is receiving a unit of packed RBCs. Which data should the nurse recognize as an indication of a septic reaction to the blood transfusion?

Choice A reason: Wiping the top of the feeding container with alcohol is not a priority action, as it is not essential for infection control or safety. The nurse should use a sterile technique when opening and handling the feeding container.

Choice B reason: Placing the head of the client's bed at a 30° angle or higher is a priority action, as it can prevent aspiration or regurgitation of the feeding solution into the lungs, which can cause pneumonia or respiratory distress.

Choice C reason: Rinsing the feeding bag with water once the feeding is complete is not a priority action, as it can be done after ensuring that the client has tolerated the feeding well and has no signs of complications.

Choice D reason: Documenting the client's response to the feeding is not a priority action, as it can be done after performing other interventions and assessments that are more urgent and important for the client's well-being.

Choice A: This is correct because suction equipment is essential for clearing the airway of secretions or vomitus during or after a seizure. The nurse should have suction equipment ready and accessible at the client's bedside at all times.

Choice B: This is incorrect because backboard is not needed for a client who has a seizure disorder. Backboard is used for immobilizing the spine in case of a suspected spinal injury.

Choice C: This is incorrect because padded tongue blades are not recommended for a client who has a seizure disorder. Padded tongue blades can cause injury to the teeth, gums, or tongue if inserted during a seizure. The nurse should never force anything into the mouth of a client who is having a seizure.

Choice D: This is incorrect because wrist restraints are not indicated for a client who has a seizure disorder. Wrist restraints can cause injury or skin breakdown if applied during a seizure. The nurse should never restrain or restrict the movements of a client who is having a seizure.