Blood administration, shock, trauma

A client wishes to donate blood for a family member and asks the nurse about the procedure for identifying compatibility. The nurse tells the client that which test will be done to test compatibility?

Indirect Coombs

One unit of packed red blood cells has been prescribed for a client postoperatively because the client's hemoglobin level is low. The primary health care provider prescribes diphenhydramine to be administered before the administration of the transfusion. Why is this medication being given?

Prevent a rash and pruritus

The licensed practical nurse (LPN) renders aid at an automobile accident where several victims sustained injury. Which actions would the LPN take to offer first aid assistance? Select all that apply.

1 Look for Medic-Alert bracelets. 2Attend the most seriously injured first. 3Try to determine the mechanism of injury.

A client is going to be transfused with a unit of packed red blood cells (PRBCs). The nurse understands that it is necessary to remain with the client for what time period after the transfusion is started?

15 minutes

The licensed practical nurse is assisting the registered nurse (RN) in the care of a child who is receiving a blood transfusion and notifies the RN if the child displays which signs/symptoms of fluid overload? Select all that apply.

4Dry cough 5Distended neck veins

The nurse is assisting in the preparation of a client for a blood transfusion. Which item is the most important for the completion of the identification process?

Identification bracelet

A client requiring upcoming surgery is extremely anxious about the need for a possible blood transfusion and is concerned about the risk of infection from contaminated blood. The nurse suggests that the client consider which as an effective method to minimize this risk?

Arrange an autologous blood donation before the planned surgery.

The nurse is assisting in monitoring a client who is receiving a transfusion of packed red blood cells. Before leaving the room, the nurse tells the client that it is important to immediately report which sign if it occurs?

Backache

The nurse is assisting with caring for a client who is receiving a unit of packed red blood cells (PRBCs). The nurse would tell the client that it is most important to report which signs immediately?

Chills, itching, or rash

A client receiving a blood transfusion begins to exhibit flushing, stridor, and a drop in blood pressure. The nurse would obtain which medication from the emergency cart to have ready for use as prescribed?

Epinephrine

The nurse enters a client's room to check the client who began receiving a blood transfusion 45 minutes earlier. The client is flushed and dyspneic. The nurse listens to the client's lung sounds and notes the presence of crackles in the lung bases. The nurse determines that this client is most likely experiencing which complication of blood transfusion therapy?

Fluid (circulatory) overload

The nurse is monitoring a client receiving a blood transfusion for circulatory overload. The nurse understands that which is a clinical indication of circulatory overload?

Moist, productive cough

Due to an extreme staff shortage, the nurse has been sent to the intensive care unit to assist registered nurses in the care of clients. The nurse understands that which factor is most important to consider when treating a client with cardiogenic shock?

Restriction of volume expanders because of secondary pulmonary edema

A client who was receiving a blood transfusion has experienced a transfusion reaction. The nurse sends the blood bag that was used for the client to which area?

The blood bank

The nurse takes a client's temperature before giving a blood transfusion. The temperature is 100° F (37.7° C) orally. The nurse reports the finding to the registered nurse (RN) and anticipates that which action will take place?

The blood will be held, and the primary health care provider (PHCP) will be notified.

The primary health care provider prescribes one unit of packed red blood cells to infuse over 4 hours. One unit of blood contains 250 mL, and the drop factor is 10 gtts/1 mL. Although an infusion pump will be used, the registered nurse asks the licensed practical nurse (LPN) to assist with monitoring the flow rate during the infusion. The LPN monitors the flow rate, knowing that how many gtt/min would infuse? Fill in the blank and round answer to the nearest whole number.

10 gtts/min

A registered nurse has just hung a 250-mL bag of packed red blood cells (PRBCs) on a client. The licensed practical nurse assisting in caring for the client plans to remain with the client for at least how many minutes following the start of the infusion?

15 minutes

One unit of packed red blood cells is infusing into a client over a 4-hour period. The unit of blood contains 250 mL. The drop factor is 15 drops (gtts) per 1 mL. The nurse determines that the flow rate would be set at how many drops per minute? Fill in the blank and round answer to the nearest whole number.

16 gtts/min

The nurse is assisting with caring for a client who has received a transfusion of platelets. The nurse determines that the client is benefiting most from this therapy if the client exhibits which finding?

A decrease in oozing from puncture sites and gums

A client who had a myocardial infarction is at risk for cardiogenic shock. The nurse assisting in planning care understands that the primary cause of cardiogenic shock results from which process?

A pump failure and reduction in cardiac output

The nurse responds to an external disaster (a mass casualty event) that occurred in a large city when a building collapsed. There are numerous victims that require treatment. Which victim would the nurse attend to first?

A victim with a partial amputation of a leg who is bleeding profusely

The nurse is assisting with caring for a client who will receive a unit of blood. Just before the infusion, it is most important for the nurse to check which item?

Vital signs

When assisting in the identification process required before a blood transfusion, which action will the nurse take when it is noted that all of the necessary information is correct, except for the client's name?

Call the blood bank about the discrepancy.

The nurse plans care understanding that the primary reason clients experience vasodilation in septic shock is because:

There is a release of endotoxins from bacteria.

A client who is receiving a blood transfusion pushes the call light for the nurse. When entering the room, the nurse notes that the client is flushed, dyspneic, and complaining of generalized itching. How would the nurse correctly interpret these findings?

Transfusion reaction

The nurse is monitoring a client who is receiving a unit of packed red blood cells. Within an hour after the initiation of a transfusion, the nurse finds the client to be restless, with reports of chills and back pain. The nurse notes that there is dark urine in the Foley catheter drainage bag. The nurse interprets that the client is experiencing which reaction?

Acute hemolytic