A nurse is assisting to monitor a client who is receiving a blood transfusion.
Which of the following findings should the nurse report to the charge nurse as an indication of an allergic blood transfusion reaction?

Choice A rationale

Stridor is a high-pitched, harsh sound heard on inspiration, indicative of upper airway obstruction or laryngeal edema. Following endotracheal tube removal (extubation), inflammation or trauma to the vocal cords or surrounding laryngeal structures can cause swelling. This significant narrowing of the glottic opening impairs airflow and constitutes a respiratory emergency requiring immediate reporting and intervention to prevent complete airway occlusion.

Choice B rationale

Deep breathing is a desirable finding post-extubation, often encouraged as part of pulmonary hygiene. It helps to re-expand collapsed alveoli (atelectasis), improve gas exchange, and promote the clearance of secretions. This finding suggests adequate respiratory muscle function and is a positive indicator of successful extubation and lung recruitment.

Choice C rationale

A strong cough is an essential protective airway reflex and a positive finding post-extubation. It indicates the return of an effective glottic seal and the ability to generate sufficient intrathoracic pressure to clear secretions from the trachea and lower airways. An intact, forceful cough reduces the risk of aspiration and post-extubation pneumonia.

Choice D rationale

Crackles (rales) are short, discontinuous, popping sounds often associated with the opening of small airways and alveoli that contain fluid or are collapsed. While common after mechanical ventilation due to fluid shifts or atelectasis, they usually represent lower airway issues. Stridor, however, signifies an immediate, life-threatening upper airway problem and is the priority finding to report.

Choice A rationale

Breaking needles in half is a dangerous practice that increases the risk of accidental percutaneous injury (needlestick) from shattered or flying fragments. This action is strongly contraindicated by Occupational Safety and Health Administration (OSHA) regulations and safe injection practices, which mandate immediate disposal of intact, used sharp objects into designated puncture-proof containers to prevent pathogen transmission.

Choice B rationale

Recapping needles is generally prohibited, especially using a two-handed technique, as it is the most common mechanism for sustaining a needlestick injury. Placing a capped needle in a regular wastebasket is incorrect and unsafe, as sharps must be disposed of immediately in a proper, rigid, puncture-proof sharps container at the point of use to contain biohazards.

Choice C rationale

Not recapping the needle on an Arterial Blood Gas (ABG) specimen is a critical safety measure consistent with the "never recap a contaminated needle" rule. ABG collection kits often contain a safety device or require immediate, one-handed disposal of the needle into a sharps container to minimize exposure risk to bloodborne pathogens like Hepatitis B, C, and HIV.

Choice D rationale

Placing uncapped needles in a puncture-proof container immediately after use adheres to stringent safety guidelines to prevent needlestick injuries. This practice ensures sharps are contained in a properly labeled, rigid, leak-proof receptacle that is closed when full, thereby safeguarding healthcare workers and environmental services personnel from accidental exposure.