A nurse is monitoring a patient who is receiving a blood transfusion.


Which of the following symptoms should the nurse report to the charge nurse as a sign of an allergic blood transfusion reaction?

Choice A rationale:

It is not necessary to remind a patient to avoid turning from side to side after femoral artery catheterization. Restricting movement in this way could actually increase the risk of complications such as deep vein thrombosis (DVT).

Early ambulation is generally encouraged to promote circulation and prevent blood clots.

Patients are typically allowed to turn and reposition themselves as needed for comfort, unless there are specific contraindications.

Choice B rationale:

Keeping the patient in a high-Fowler's position for 6 hours is not a standard recommendation following femoral artery catheterization.

The patient's position should be based on their individual needs and comfort level.

In some cases, a slight elevation of the head of the bed may be helpful to promote venous return, but prolonged high-Fowler's positioning is not necessary.

Choice C rationale:

Passive range-of-motion exercises are not typically performed on the affected extremity immediately following femoral artery catheterization.

This is because there is a risk of dislodging the catheter or causing bleeding at the puncture site.

Once the catheter has been removed and the puncture site has healed, gentle range-of-motion exercises may be recommended to help maintain joint mobility.

Choice D rationale:

Checking pedal pulses every 15 minutes is essential to assess for adequate circulation to the lower extremities following femoral artery catheterization.

This is because there is a risk of complications such as thrombosis or embolism, which can compromise blood flow to the legs and feet.

If the pedal pulses are weak or absent, it could indicate a serious problem that requires immediate intervention.

Choice B rationale:

Stridor is a high-pitched, wheezing sound that is heard during inspiration. It is caused by a narrowing or obstruction of the upper airway. This can be a serious complication after extubation, as it can indicate that the patient is not able to breathe adequately. Stridor can be caused by a number of factors, including:

Laryngeal edema: This is swelling of the larynx, which can be caused by irritation from the endotracheal tube.

Laryngospasm: This is a sudden constriction of the muscles of the larynx, which can be caused by irritation or by a foreign body in the airway.

Vocal cord paralysis: This is a loss of movement of the vocal cords, which can be caused by damage to the nerves that control them.

Blood or secretions in the airway: These can obstruct the airway and cause stridor.

It is important for the nurse to report stridor to the provider immediately so that the cause can be identified and treated. Treatment may include:

Oxygen therapy: This can help to improve the patient's breathing.

Medications: These may be used to reduce inflammation or to relax the muscles of the airway. Reintubation: This may be necessary if the patient is not able to breathe adequately on their own.