Blood Transfusion NCLEX
The nurse is caring for a 70-year-old client with hypovolemia who is receiving a blood transfusion. Assessment findings reveal crackles on chest auscultation and distended neck veins. What is the nurse's initial action? A. Slow the transfusion. B. Document the finding as the only action. C. Stop the blood transfusion and turn on the normal saline. D. Assess the client's pupils."
Answer A is correct. The client is exhibiting symptoms of fluid volume excess; slowing the rate is the proper action. The nurse would not stop the infusion of blood, as in answer C, and answers B and D would not help.
During a blood transfusion a client develops chills and a headache, what is the priority nursing action A) cover the client B) stop the transfusion at once C) notify the physician immediately D) decrease the rate of blood infusion
B) stop the transfusion because chills, headache, and nausea are all signs of transfusion reaction
"The nurse determines that a client is having a transfusion reaction. After the nurse stops the transfusion, which action should immediately be taken next? 1. remove the intravenous line 2. run a solution of 5% dextrose in water 3.run normal saline at a keep-vein-open rate 4. obtain a culture of the tip of the catheter device removed from the client"
Correct 3 If the nurse suspects a transfusion reaction, the nurse stops the transfusion and infuses normal saline at a keep-vein-open rate pending further physician prescriptions. This maintains a patent IV access line and aids in maintaining the client's intravascular volume. The nurse would not remove the IV line because then there would be no IV access route. Obtaining a culture of the tip of the catheter device removed from the client is incorrect. First the catheter should not be removed. Second, cultures are performed when infection, not transfusion reaction, is suspected. Normal saline is the solution of choice over solutions containing dextrose because saline does not cause red blood cells to clump.
The nurse who is about to give a blood transfusion knows that blood cells start to deteriorate after a certain period of time. Which of the following items is important to check regarding the age of blood cells before the transfusion is begun? A. Expiration date B. Presence of clots C. Blood group and type D. Blood identification number"
Correct A
Halfway through the administration of blood, the female client complains of lumbar pain. After stopping the infusion the nurse should: a. Increase the flow of normal saline b. Assess the pain further c. Notify the blood bank d. Obtain vital signs."
Correct A The blood must be stopped at once, and then normal saline should be infused to keep the line patent and maintain blood volume.
". A unit of packed red blood cells has been prescribed for a client with low hemoglobin and hematocrit levels. The nurse notifies the blood bank of the order, and a blood specimen is drawn from the client for typing and cross-matching. The nurse receives a telephone call from the blood bank and is informed that the unit of blood is ready for administration. Arrange the actions in order of priority that the nurse should take to administer the blood. a) hang the bag of blood b) obtain the unit of blood from the bank c) ensure that an informed consent has been signed d) verify the physician's order for the blood transfusion e) insert an 18 or 19-gauge IV catheter into the client f) ask a licensed nurse to assist in confirming blood compatibility and verifying client identity."
D,C, E, B, F, A - The nurse would first verify the physician's order for the blood transfusion and ensure that the client has been informed about the procedure and has signed an informed consent. Once this has been done, the nurse would ensure that at least an 18- or 19-gauge intravenous needle is inserted into the client. Next, the blood is obtained from the blood bank, then two nurses must together check the label on the blood product against the client's identification number, blood group, and complete name.The nurse should measure vital signs and assess lung sounds and then hang the transfusion."`
"The client is admitted to the ED after a MVA. The nurse notes profuse bleeding from a right-sided abdominal injury. Which intervention should the nurse implement first? 1.) Type and crossmatch for RBCs immediately (STAT). 2.) Initiate an IV with an 18-gauge needle and hang normal saline. 3.) Have the client sign a consent for an exploratory laparotomy. 4.) Notify the significant other of the client's admission.
*2.) The first action in a situation in which the nurse suspects the client has a fluid volume loss is to replace the volume as quickly as possible (CORRECT). 1.) This should be done, but the client requires the IV fluids first because they are at risk for shock (omit #1). 3.)The client will probably need to have surgery to correct the source of the bleeding, but stabilizing the client with fluid resuscitation is first priority (omit #3). 4.) This is the last thing on this list in order of priority (omit #4).
"The nurse receives a physician's order to transfuse fresh frozen plasma to a patient suffering from an acute blood loss. Which of the following procedures is most appropriate for infusing this blood product? A. Infuse the fresh frozen plasma as rapidly as the patient will tolerate. B. Hang the fresh frozen plasma as a piggyback to the primary IV solution. C. Infuse the fresh frozen plasma as a piggyback to a primary solution of normal saline. D. Hang the fresh frozen plasma as a piggyback to a new bag of primary IV solution without KCl."
Correct A "The fresh frozen plasma should be administered as rapidly as possible and should be used within 2 hours of thawing. Fresh frozen plasma is infused using any straight-line infusion set. Any existing IV should be interrupted while the fresh frozen plasma is infused, unless a second IV line has been started for the transfusion."
The nurse has obtained a unit of blood from the blood bank and has checked the blood bag properly with another nurse. Just before the beginning transfusion, the nurse assessess which of the following items? A. Vital signs B. Skin Color C. Urine ouput D. Latest hematocrit level.
Correct Answer A Change in vital signs during the transfusion from the baseline may indicate that a transfusion reaction is occuring. This is why nurse assesses vital signs before the procedure and again after 15 mintues. The other options do not identify assessment that are required just before beginning a transfusion.
"Before starting a transfusion of packed red blood cells for an anemic patient, the nurse would arrange for a peer to monitor his or her other assigned patients for how many minutes when the nurse begins the transfusion? A. 5 minutes B. 15 minutes C. 60 minutes D. 30 minutes"
Correct B Patients who are likely to have a transfusion reaction will more often exhibit signs within the first 15 minutes that the blood is infusing
A nurse checks a unit of blood received from the blood bank and notes the presence of gas bubbles in the bag. Which should the nurse implement? A. Return the bag to the blood bank. B. Infuse the blood using the filter tubing. C. Add 10ml of NS to the bag. D. Agitate the bag to mix contents gently.
Correct: A The nurse should return the blood to the blood bank because the gas bubbles in the bag indicate possible contamination. If the nurse were going to administer the blood, the nurse would use filter tubing to trap the particulate matter. Although normal saline can be infused concurrently with the blood, NS or any other substance should never be added to the blood in a blood bag. The blood should not be agitated this can harm the RBCs.
"Client asks the nurse whether all donor blood products are cross-matched with the recipient to prevent a transfusion reaction. select all of the following that always require cross-matching. a. packed red blood cells b. platelets c. Albumin d. Cryoprecipitates e. Fresh frozen plasma
Correct: A and E Red blood cells and plasma contain antigens and antibodies that must be matched between donor and recipient.
"The nurse is caring for a patient who is to receive a transfusion of two units of packed red blood cells. After obtaining the first unit from the blood bank, the nurse would ask which of the following health team members in the nurses' station to assist in checking the unit before adiminstration? A: Unit Secretary B: A Phlebotomist C: A Physician's Assistant D: Another Registered Nurse
Correct: D Before hanging a transfusion, the registered nurse must check the unit with ANOTHER RN or with a licensed practical (vocational) nurse, depending on agency policy. Checking blood products is not in the unit secretary's or phlebotimist's scope of practice. The physician assistant is not another RN or licensed practical nurse.
"The physician orders 2 units of packed RBCs to be administered to the client. At 0600 the night shift nurse initiates the first unit's transfusion before going off shift. At 1000 the day shift nurse notes the IV line has clotted off and the transfusion has not been completed. The nursing assessment revealed the transfusion was only approximately 75% complete. Which of the actions by the nurse is most appropriate? A. Advise the blood bank about the delay for the next unit. B. Restart another peripheral line with 0.9% NS and restart the blood transfusion with the remaining blood unit. C. Discontinue the transfusion. D. Document the amount infused thus far and continue the transfusion."
"Answer C Rationale: A unit of blood should be administered within a 4 hour period of time. The nurse should discontinue the transfusion, document the findings and notify the blood bank. The agency policy will need to be followed concerning the documentation process and notification of appropriate personnel. Continuing the transfusion with the "open" unit will expose the client to an increase risk of injury."
"Packed red blood cells have been prescribed for a client with a low hemoglobin and hematocrit levels. The nurse takes the client's temperature before hanging the blood transfusion and records 100.6 degrees orally. Which of the following is the appropriate nursing action? A) Begin the transfusion as prescribed B) Delay hanging blood and notify the physician C) Administer an antihistamine and begin the transfusion D) Administer two tablets of Tylenol and begin the transfusion"
"Correct Answer B: If the client has a temperature higher than 100 degrees, the unit of blood should not be hung until the physician is notified and has the opportunity to give further prescriptions. The physician will likely prescribe that the blood be administered regardless of the temperature, but the decision is not within the nurses's scope of practice to make. The nurse needs a physician's prescription to administer medications to the client. Options A, C, and D can all be excluded as they indicate beginning the transfusion."
"The client with O+ blood is in need of an emergency transfusion but the lab does not have any O+ blood available. Which potential unit of blood could be given to the client? "1. 0- unit 2. A+ unit 3. B+ unit 4. Any Rh+ unit"
"Correct answer: Answer 1. 1. O- negative blood is considered the universal donor because it does not contain the antigens A, B, or Rh. (AB+ is considered the universal recipient because a person with this blood type has all the anti-gens on the blood). 2.A+ blood contains the antigen A that the client will react to, causing the development of antibodies. The unit being Rh+ is compatible with the client. 3.B+ blood contains the antigen B that the client will react to, causing the development of anti-bodies. The unit being Rh+ is compatible with the client. 4.This client does not have antigens A or B on the blood. Administration of these types would cause an antigen/antibody reaction within the client's body, resulting in a massive hemolysis of the client's blood and death."
The client has a hematocrit of 22.3% and a hemoglobin of 7.7 mg/dL. The HCP has ordered two units of packed red blood cells to be transfused. Which interventions should the nurse implement? Select all that apply 1. Obtain a signed consent. 2.Initiate a 22-gauge IV. 3.Assess the client's lungs. 4.Check for allergies. 5.Hang a keep-open IV of D5W
Correct: 1, 3, 4
"73. A client brought to the emergency department states that he has accidentally been taking two times his prescribed dose of warfarin (Coumadin) for the past week. After noting that the client has no evidence of obvious bleeding, the nurse plans to do which of the following? 1. Prepare to administer an antidote. 2. Draw a sample for type and crossmatch and transfuse the client. 3. Draw a sample for an activated partial thromboplastin time (aPTT) level. 4. Draw a sample for prothrombin time (PT) and international normalized ratio (INR)."
Correct - 4
"The nurse is preparing to initiate a blood transfusion. The client has a peripheral intravenous infusion in their left arm that the physician has ordered not be slowed or rate reduced. The nurse prepares to start another line in the right arm. The client asks the nurse to use the existing site to avoid the trauma of having another line started. Which of the following statements by the nurse is correct? A. ""That will be fine"" B. "I will need to infuse the blood through a separate IV line." C. "I will let the physician know about your preferences." D. "We will need to assess the line before I can make a determination about your request.""
Answer: B "Rationale: A blood infusion must be administered via a separate IV line. The other responses indicate to the client their request is being considered"
"Which statement is the scientific rationale for infusing a unit of blood in less than four (4) hours? "1. The blood will coagulate if left out of the refrigerator for >four (4) hours. 2. The blood has the potential for bacterial growth if allowed to infuse longer. 3. The blood components begin to break down after four (4) hours. 4. The blood will not be affected; this is a laboratory procedure."
Correct 2 "1. Blood will coagulate if left out for an extended period of, but blood is stored with a preservative that prevents this and prolongs the life of the blood. 2. (CORRECT). Blood is a medium for bacterial growth, and any bacteria contaminating the unit will begin to grow if left outside of a controlled refrigerated temperature for longer than four (4) hours, placing the client at risk for septicemia. 3. Blood components are stable and do not break down after four (4) hours. 4. These are standard nursing and laboratory procedures to prevent the complication of septicemia."
The nurse is working in a blood bank facility procuring units of blood from donors. Which client would not be a candidate to donate blood? 1.The client who had wisdom teeth removed a week ago.2.The nursing student who received a measles immunization 2 months ago.3. The mother with a six (6)-week-old newborn.4.The client who developed an allergy to aspirin in childhood
Correct 3 "1. Oral surgeries are associated with transientbacteremia, and the client cannot donate for 72hours after an oral surgery.2.The client cannot donate blood following ubella immunizations for one (1) month. 3. CORRECT The client cannot donate blood for 6months after a pregnancy because of thenutritional demands on the mother. 4.Recent allergic reactions prevent donationbecause passive transference of hypersensitiv-ity can occur. This client has an allergy thatdeveloped during childhood"
A nurse has received a prescription to transfuse a client with a unit of packed red blood cells. Before explaining the procedure to the client, the nurse asks which initial questions? 1. Have you ever had a transfusion before? 2. Why do you think that you need the transfusion? 3. Have you ever gone into shock for any reason in the past? 4. Do you know the complications and risks of a transfusion?
Correct: 1 Asking the client about personal experience with tranfusion therapy provides a good starting point for client teaching about this procedure. Options 3 & 4 are not helpful because they may elicit a fearful response from the client. Although determining whether the client knows the reason for the transfusion is important, option 2 is not an appropriate statement in terms of eliciting information from the client regarding an understanding of the need for the transfusion.
A 28-year old client with cancer is afraid of experiencing a febrile reaction associated with blood transfusions. He asks the nurse if this will happen to him. The nurse's best response is which of the following? 1) Febrile reactions are caused when antibodies on the surface of blood cells in the transfusion are directed against antigens of the recipient. 2) Febrile reactions can usually be prevented by administering antipyretics and antihistamines before the start of the transfusion. 3) Febrile reactions are rarely immune-mediated reactions and can be a sign of hemolytic transfusion. 4) Febrile reactions primarily occur within 15 minutes after initiation of the transfusion and occur during the blood transfusion.
Correct: 2 The administration of antipyretics and antihistamines before initiation of the transfusion in the frequently transfused client can decrease the incidence of febrile reactions. Febrile reactions are immune-mediated and are caused by antibodies in the recipient that are directed against antigens present on the granulocytes, platelets, and lymphocytes in the transfused component. They are the most common transfusion reaction and may occur with onset, during transfusion, or hours after transfusion is completed.
A 52-year-old woman is admitted with a new diagnosis of gastrointestinal (GI) bleed. The physician has ordered the client to receive 2 units of packed red blood cells (PRBCs) for a hemoglobin (Hgb) of 6.8g/dL. The nurse begins the infusion of the first unit at 100mL/hr. Fifteen minutes after the start of the infusion, the client complains that she is feeling chilled, is short of breath, and is experiencing lumbar pain rated 8 on a 1-10 scale. Which of the following should be the nurse's FIRST action. "1. Obtain vital signs and notify the physician of potential reaction 2. Slow the infusion to 75mL/hr and reassess in 15 minutes 3. Stop the infusion and run normal saline (NS) to keep the vein open (KVO) 4. Administer PRN pain medication as ordered, apply oxygen at 2 L/min, and provide an additional blanket"
Correct: 3 "1. ""Obtain vital signs..."" - vital sings should be obtained, and the physician notified after treatment is discontinue. The unit in quesiton should not be restarted, and any other units that were issued should not be implemented. 2. ""Slow the infusion..."" - just slowing the infusino will not resolve the issue of an allergic reaction to the treatment 3. ""Stop the infusion..."" - (CORRECT): The symptoms of feeling chilllded, being short of breath, and having back pain coudl indicate an acute hemolytic reaction. This medical emergency requires swift action on the part of the nurse, including immediately discontinuing the infusion, flushing the IV site, and saving the unit of blood in question for testing. 4. ""Administer PRN pain medication..."" - Treating the symptoms of the reaction will not resolve the issue of an allergic reactio to the treatment"
The nurse enters a client's room to assess the client, who began receiving a blood transfusion 45 minutes earlier, and notes that the client is flushed and dyspneic. On assessment, the nurse auscultates the presence of crackles in the lung bases. The nurse determines that this client most likely is experiencing which complication of blood transfusion therapy? 1) Bacteriemia. 2) Hypovolemia. 3) Fluid overload 4) Transfusion reaction
Correct: 3 With fluid overload, the client has the presence of crackles in addition to dyspnea. An allergic reation, a type of blood transfusion reaction, would produce symptoms such as flushing, dyspnea, itching, and a generalized rash. Hypovolemia is not complication of blood transfusions. With bacteriemia, the client would have fever, a symptom not presented.
"The nurse and unlicensed nursing assistant are caring for clients on an oncology floor. Which nursing task would be delegated to the unlicensed nursing assistant? "1. Assess the urine output on a client who has had a blood transfusion reaction. 2. Take the first 15 minutes of vital signs on a client receiving a unit of PRBCs. 3. Auscultate the lung sounds of a client prior to a transfusion. 4. Assist a client who received ten (10) units of platelets in brushing teeth.
Correct: 4 "1. Unlicensed nursing assistants cannot assess. The nurse cannot delegate assessment. 2. The likelihood of a reaction is the greatest during the first 15 minutes of a transfusion.The nurse should never leave the client until after this time. The nurse should take and assess the vital signs during this time. 3. Auscultation of the lung sounds and administering blood based on this information are the nurse's responsibility. Any action requiring nursing judgment cannot be delegated. 4. The unlicensed nursing assistant can assist a client to brush the teeth. Instructions about using soft-bristle toothbrushes and the need to report to the nurse any pink or bleeding should be given prior to delegating the procedure. (CORRECT) TEST-TAKING HINT: The test taker must be aware of delegation guidelines. The nurse cannot delegate assessment or any intervention requiring nursing judgment. Options "1," "2," and "3" require judgment and cannot be delegated to an unlicensed assistant."
"The nurse is administering packed red blood cells (PRBCs) to a client. The nurse should first: "1. Discontinue the I.V. catheter if a blood transfusion reaction occurs. 2. Administer the PRBCs through a percutaneously inserted central catheter line with a 20-gauge needle. 3. Flush PRBCs with 5% dextrose and 0.45% normal saline solution. 4. Stay with the client during the first 15 minutes of infusion.
Correct: 4 The most likely time for a blood transfusion reaction to occur is during the first 15 minutes or first 50 mL of the infusion. If a blood transfusion reaction does occur, it is imperative to keep an established I.V. line so that medication can be administered to prevent or treat cardiovascular collapse in case of anaphylaxis. PRBCs should be administered through a 19-gauge or larger needle; a peripherally inserted central catheter line is not recommended, in order to avoid a slow flow. RBCs will hemolyze in dextrose or lactated Ringer's solution and should be infused with only normal saline solution.
"The nurse understands that the client with pernicious anemia will have which distinguishing laboratory findings? "a. Schilling's test, elevated b. Intrinsic factor, absent. c. Sedimentation rate, 16 mm/hour d. RBCs 5.0 million
Correct: B ANSWER B. The defining characteristic of pernicious anemia, a megaloblastic anemia, is lack of the intrinsic factor, which results from atrophy of the stomach wall. Without the intrinsic factor, vitamin B12 cannot be absorbed in the small intestines, and folic acid needs vitamin B12 for DNA synthesis of RBCs. The gastric analysis was done to determine the primary cause of the anemia. An elevated excretion of the injected radioactive vitamin B12, which is protocol for the first and second stage of the Schilling test, indicates that the client has the intrinsic factor and can absorb vitamin B12 into the intestinal tract. A sedimentation rate of 16 mm/hour is normal for both men and women and is a nonspecific test to detect the presence of inflammation. It is not specific to anemias. An RBC value of 5.0 million is a normal value for both men and women and does not indicate anemia.
"A month after receiving a blood transfusion an immunocompromised male patient develops fever, liver abnormalities, a rash, and diarrhea. The nurse would suspect this patient has: a. Nothing related to the blood transfusion b. Graft-versus-host disease (GVHD) c. Myelosuppression d. An allergic response to a recent medication"
Correct: B GVHD occurs when white blood cells in donor blood attack the tissues of an immunocompromised recipient. This process can occur within a month of the transfusion. Options 1 and 4 may be a thought, but the nurse must remember that immunocompromised transfusion recipients are at risk for GVHD
A new RN is preparing to administer packed red blood cells (PRBCs) to a client whose anemia was caused by blood loss after surgery. Which action by the new RN requires that you, as charge nurse, intervene immediately? "a. The new RN waits 20 minutes after obtaining the PRBCs before starting the infusion. b. The new RN starts an intravenous line for the transfusion using a 22-gauge catheter. c. The new RN primes the transfusion set using 5% dextrose in lactated Ringer's solution. d. The new RN tells the client that the PRBCs may cause a serious transfusion reaction."
Correct: C ANSWER C - Normal saline, an isotonic solution, should be used when priming the IV line to avoid causing hemolysis of RBCs. Ideally, blood products should be infused as soon as possible after they are obtained; however, a 20-minute delay would not be unsafe. Large-gauge IV catheters are preferable for blood administration; if a smaller catheter must be used, normal saline may be used to dilute the RBCs. Although it is appropriate to instruct clients to notify the nurse if symptoms of a transfusion reaction such as shortness of breath or chest pain occur, it will cause unnecessary anxiety to indicate that a serious reaction is likely to occur. Focus: Prioritization
"Which organ is at greatest risk due to the effects of hemolytic anemia? "A. Heart B. Spleen C. Kidney D. Liver
Correct: C For all causes of hemolysis, a major focus of treatment is to maintain renal function. When RBCs are hemolyzed, the hemoglobin molecule is released and filtered by the kidneys. The accumulation of hemoglobin molecules can obstruct the renal tubules and lead to acute tubular necrosis. This is why clients feel lower back pain.
The nurse is aware that the following solutions is routinely used to flush an IV device before and after the administration of blood to a patient is: "a. 0.9 percent sodium chloride b. 5 percent dextrose in water solution c. Sterile water d. Heparin sodium
Correct:" A "0.9 percent sodium chloride is normal saline. This solution has the same osmolarity as blood. Its use prevents red cell lysis. The solutions given in options 2 and 3 are hypotonic solutions and can cause red cell lysis. The solution in option 4 may anticoagulate the patient and result in bleeding."
About ten minutes after the nurse begins an infusion of packed RBCs, the patient complains of chills, chest and back pain, and nausea. His face is flushed, and he's anxious. Which is the priority nursing action? 1. Administering antihistamines STAT for an allergic reaction. 2. Notifying the physician of a possible transfusion reaction. 3. Obtaining a urine and serum specimen to send to the lab immediately. 4. Stopping hte transfusion and maintaining a patent IV catheter."
The correct answer is 4. The patietn is experiencing a transfusion reaction. The immediate nursing action is to stop the transfusion and maintain a patent IV line. The other options may be indicated but aren't the priority in this case.