A nurse is caring for a client who has a new onset of hyperglycemic hyperosmolar state (HHS). Which of the following interventions by the nurse is the highest priority?

C. Suspending the infusion of packed RBCs is essential to prevent further administration of the blood product that may be causing the adverse reaction. Stopping the infusion allows for further assessment and appropriate management of the client's symptoms.
A. The client's symptoms of chills, lower back pain, and nausea suggest a potential transfusion reaction rather than respiratory compromise.
B. Collecting a urine sample may be indicated to assess for hemolysis or kidney injury, which can occur as a result of a transfusion reaction. However, this action can be deferred until after immediate interventions to manage the suspected reaction.
D. While checking the client's vital signs is important in assessing the severity of the reaction and the client's overall condition, it is not the first action to take when a transfusion reaction is suspected.

A. Neurovascular assessment should be the nurse's priority assessment. Postoperative patients, especially those who have undergone orthopedic surgery such as ORIF of the femur, are at risk for neurovascular compromise due to factors such as positioning during surgery, edema, and postoperative pain.
B. Pain assessment is important for overall patient comfort and well-being, but in the immediate postoperative period following ORIF of the femur, neurovascular assessment takes priority.
C. The Braden scale is used to assess a patient's risk for pressure ulcers. While pressure ulcer risk assessment is important for overall patient care, it is not the priority assessment for a patient who is postoperative following ORIF of the femur.
D. The Morse Fall Risk scale is used to assess a patient's risk for falls. While fall risk assessment is important for patient safety, it is not the priority assessment for a patient who is postoperative following ORIF of the femur.