A nurse is collecting data on a patient who is receiving a unit of PRBCs.
Which of the following symptoms is a sign of an allergic transfusion reaction?

The correct answer is Choice A: Don sterile gloves before inserting the indwelling urinary catheter.

Choice A rationale:

Donning sterile gloves is crucial to prevent infection during the insertion of an indwelling urinary catheter. Maintaining aseptic technique is essential to avoid introducing pathogens into the urinary tract.

Choice B rationale:

Applying an oil-based lubricant to the catheter is not recommended as it can interfere with the sterility of the procedure and potentially cause irritation or infection.

Choice C rationale:

Testing the balloon before insertion is important, but it is not the first step in the process. The priority is to ensure that the nurse is using sterile gloves to maintain aseptic technique.

Choice D rationale:

Using one cotton swab to clean the patient’s urinary meatus is not sufficient for proper aseptic technique. The area should be cleaned thoroughly with appropriate antiseptic solutions and sterile supplies.

The correct answers are Choices A and C.

Choice A rationale: Ignoring the urge to defecate can lead to constipation because the longer stool remains in the colon, the more water is absorbed from it, making it harder and more difficult to pass. This can lead to a cycle of further constipation and discomfort.

Choice B rationale: Increased fiber in the diet usually helps prevent constipation by adding bulk to the stool and making it easier to pass. Therefore, it is not a cause of constipation, but rather a preventive measure.

Choice C rationale: Excessive laxative use can lead to dependence on laxatives for bowel movements and can disrupt normal bowel function. Over time, this can lead to constipation as the bowel becomes less responsive to normal stimuli.

Choice D rationale: Increased activity generally helps to prevent constipation by stimulating bowel motility. Physical exercise can enhance the efficiency of the digestive system, so it is not a cause of constipation.