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?

Choice A rationale:

Positioning the client supine is not the immediate next step after performing hand hygiene when preparing to remove a patient’s urinary catheter. While it is important to ensure the patient is in a comfortable and appropriate position for the procedure, the immediate next step should be focused on ensuring the area is clean to prevent infection.

Choice B rationale:

After performing hand hygiene, the nurse should cleanse the perineal area with an antiseptic. This is to ensure that the area is clean before proceeding with the removal of the urinary catheter. It helps to prevent the introduction of bacteria into the urinary tract, which could lead to a urinary tract infection. The use of an antiseptic is recommended to kill any potential pathogens that may be present.

Choice C rationale:

Deflating the balloon halfway and then pulling out the catheter is not the immediate next step after performing hand hygiene. This step is usually done later in the process. Before deflating the balloon, it is important to ensure that the area is clean to prevent infection. Moreover, deflating the balloon halfway could potentially cause discomfort or injury to the patient. The balloon should be fully deflated before the catheter is removed.

Choice D rationale:

Having the client bear down during removal is not the immediate next step after performing hand hygiene. This action might be suggested during the actual removal of the catheter to aid in the process, but it is not the immediate next step. The focus right after hand hygiene should be on cleaning the area to prevent infection.

Choice A rationale:

Circulatory overload, also known as hypervolemia or fluid overload, is a condition where the body has too much fluid. This excess fluid, especially in the circulatory system, can lead to a rapid heartbeat. This is because the heart needs to work harder to pump the increased volume of blood, leading to an increased heart rate.

Choice B rationale:

Weight loss is not typically associated with circulatory overload. In fact, quick weight gain might be observed due to the excess fluid in the body.

Choice C rationale:

Low blood pressure is not a common symptom of circulatory overload. On the contrary, high blood pressure can occur because the excess fluid in the circulatory system puts more pressure on the blood vessel walls.

Choice D rationale:

Excessive sweating is not a direct symptom of circulatory overload. However, symptoms such as shortness of breath and swelling in certain areas of the body are more common.