A nurse is caring for a client who has leukemia. Which of the following findings is the highest priority for the nurse to report to the provider?

Choice A reason: Hypertension is not a sign of a septic reaction, but rather a sign of a hypertensive or circulatory overload reaction to the blood transfusion.

Choice B reason: Distended neck veins are not a sign of a septic reaction, but rather a sign of a circulatory overload or cardiac failure reaction to the blood transfusion.

Choice C reason: Polyuria is not a sign of a septic reaction, but rather a sign of a hemolytic or renal failure reaction to the blood transfusion.

Choice D reason: Vomiting is a sign of a septic reaction, which occurs when the blood transfusion is contaminated with bacteria. Other signs of a septic reaction include fever, chills, hypotension, and shock.

Choice A reason: Staying nearby can provide comfort and support is not an appropriate response, as it does not acknowledge or validate the partner's feelings of grief and loss. The nurse should listen empathetically and encourage the partner to express their emotions.

Choice B reason: I can understand your feelings of sadness is an appropriate response, as it shows empathy and compassion for the partner's situation and allows them to feel heard and understood.

Choice C reason: I will be positive and optimistic for you is not an appropriate response, as it implies that the partner's feelings are negative or inappropriate and that they need to be changed or fixed. The nurse should respect and accept the partner's feelings without judging or minimizing them.

Choice D reason: You should try to be strong for him is not an appropriate response, as it places pressure and expectations on the partner and discourages them from showing their true feelings. The nurse should support and empower the partner without imposing their own values or beliefs.