A client expresses anger when the nurse does not respond within 5 minutes of ringing for the nurse. Which response by the nurse is appropriate?

Choice A rationale

The client’s symptoms of itching, anxiety, a flushed face, and hives after the initiation of a blood transfusion are indicative of an allergic reaction. These symptoms suggest that the client may be having a reaction to the transfused blood, which can occur if the client’s immune system reacts against the blood cells or other components of the transfused blood.

Choice B rationale

While some side effects can occur during a blood transfusion, the symptoms the client is experiencing are not normal side effects of the procedure. Normal side effects might include a slight fever or chills.

Choice C rationale

Although the client is experiencing anxiety, this is likely a symptom of the allergic reaction rather than an indication of an anxiety disorder.

Choice D rationale

Hypersensitivity to the IV gauge material is unlikely to cause the symptoms the client is experiencing. Hypersensitivity reactions to medical device materials are rare and would not typically cause systemic symptoms like itching and hives.

The correct answers are Choices A, B, and C.

Choice A rationale: Passive range-of-motion exercises should be performed more frequently than once each day to maintain joint mobility, prevent contractures, and stimulate circulation. Performing them only once daily is inadequate for a client with paraplegia who is immobile.

Choice B rationale: Nonblanchable erythema is a sign of a stage 1 pressure ulcer, indicating that the skin is at risk of further breakdown and infection. Immediate intervention is required to prevent progression to more severe pressure injuries.

Choice C rationale: Plantar flexion contractures can lead to significant long-term disability and complications, such as difficulty in ambulation and pain. These contractures require intervention through more frequent range-of-motion exercises, splinting, or physical therapy to prevent worsening.

Choice D rationale: Pedal pulses that are 2+ bilaterally are within normal limits and indicate adequate peripheral circulation. This finding does not require intervention.