A nurse is caring for a client who has Clostridium difficile. When applying a cover gown, which of the following techniques should the nurse use?

A. Preferred bath time is incorrect. While important for comfort and care planning, the preferred bath time is not critical information for change-of-shift report unless directly relevant to immediate care.

B. Time of last pain medication is correct. Information about the last dose of pain medication is essential to assess the client’s current pain level and determine if another dose is required. It also helps to plan for ongoing pain management and monitor for signs of over-medication or under-medication.

C. Steps required for dressing change is incorrect. While it is important to know the steps for dressing changes, this would typically be included in the written care instructions, not necessarily as part of the verbal change-of-shift report.

D. Admission vital signs is incorrect. Admission vital signs are not typically necessary for change-of-shift report unless there has been a significant change in the client’s condition since admission. It is more important to focus on current assessments and interventions.

A. An anaphylactic reaction is correct. Symptoms such as urticaria (hives) and wheezing indicate a severe allergic reaction, which can progress to anaphylaxis. This reaction is caused by a hypersensitivity to plasma proteins in the transfused blood and requires immediate intervention, including stopping the transfusion and administering epinephrine.

B. An acute hemolytic reaction is incorrect. This reaction occurs when the recipient's immune system attacks incompatible donor red blood cells, leading to symptoms such as fever, chills, flank pain, hypotension, and hemoglobinuria. Urticaria and wheezing are not characteristic symptoms of this reaction.

C. A febrile reaction is incorrect. Febrile reactions are the most common type of transfusion reaction and are typically characterized by fever, chills, and headache, rather than urticaria or wheezing.

D. Circulatory overload is incorrect. This reaction occurs when too much fluid is infused too quickly, leading to dyspnea, hypertension, and pulmonary edema. While respiratory distress can occur, it is not accompanied by urticaria, which is specific to an allergic reaction.