A nurse is collecting data on a client who has urinary retention. Which of the following findings should the nurse expect?

Choice A reason: Flank pain is not a sign of an allergic transfusion reaction. Flank pain is a pain in the side of the abdomen or back, usually caused by kidney problems, such as infection, stones, or injury. Flank pain can be a sign of a hemolytic transfusion reaction, which is a serious complication that occurs when the donor blood is incompatible with the recipient's blood type.

Choice B reason: Elevated blood pressure is not a sign of an allergic transfusion reaction. Elevated blood pressure is a condition where the force of the blood against the artery walls is too high, which can increase the risk of heart disease, stroke, and kidney damage. Elevated blood pressure can be a sign of a hypertensive transfusion reaction, which is a rare complication that occurs when the donor blood has a higher sodium level than the recipient's blood.

Choice C reason: Distended neck veins are not a sign of an allergic transfusion reaction. Distended neck veins are a sign of increased pressure in the right side of the heart or the superior vena cava, which can be caused by heart failure, pulmonary hypertension, or obstruction. Distended neck veins can be a sign of a circulatory overload transfusion reaction, which is a complication that occurs when the blood volume or rate of infusion is too high for the recipient's cardiovascular system.

Choice D reason: Wheezing is a sign of an allergic transfusion reaction. Wheezing is a high-pitched whistling sound that occurs when the airways are narrowed or inflamed, which can cause difficulty breathing, coughing, or chest tightness. Wheezing can be a sign of an allergic transfusion reaction, which is a hypersensitivity response to the donor blood or its components, such as plasma proteins, antibodies, or preservatives. An allergic transfusion reaction can range from mild to severe, and can be treated with antihistamines, corticosteroids, or epinephrine.

Choice A reason: Storing oxygen tanks upright is not a necessary instruction for home oxygen therapy. Oxygen tanks can be stored horizontally or vertically, as long as they are secured and away from heat sources.

Choice B reason: Using petroleum-based ointments to moisturize lips is not advisable for clients who use home oxygen therapy. Petroleum-based products can ignite in the presence of oxygen and cause burns. The nurse should recommend water-based products instead.

Choice C reason: Keeping oxygen tanks 4 feet away from an electric stove is a safety measure for home oxygen therapy. Oxygen is a flammable gas and can cause a fire or explosion if exposed to heat or sparks. The nurse should also instruct the client to avoid smoking, candles, and other open flames.

Choice D reason: Choosing a wool blanket when using oxygen is not a good idea for home oxygen therapy. Wool is a synthetic material that can generate static electricity and ignite oxygen. The nurse should suggest cotton or other natural fabrics instead.