Chapter 14: Administration of Blood Products

The nurse has obtained a unit of blood from the blood bank and has checked the blood bag prop- erly with another nurse. Just before beginning the transfusion, the nurse should assess which pri- ority item? 1.Vitalsigns 2. Skin color 3. Urine output 4. Latest hematocrit level

1 Rationale: Achange in vital signs during the transfusion from baseline may indicate that a transfusion reaction is occurring. This is why the nurse assesses vital signs before the procedure and again after the first 15 minutes and thereafter per agency policy. The other options do not identify assessments that are a priority just before beginning a transfusion. Test-Taking Strategy: Note the strategic word, priority. This tells you that more than one of the options may be partially or totally correct and that the correct option needs to be assessed for possible comparison during the transfusion. Use the ABCs— airway, breathing, and circulation—to direct you to the correct option. Review: Blood transfusions

The 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 should ask which initial question? 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?"

1 Rationale: Asking the client about personal experience with transfusion therapy provides a good starting point for client teaching about this procedure. Questioning about previous history of shock and knowledge of complications and risks of transfusion is not helpful because it may elicit a fearful response from the client. Although determining whether the client knows the reason for the transfusion is important, it is not an appropriate statement in terms of eliciting information from the client regarding an understanding of the need for the transfusion. Test-TakingStrategy:Notethestrategicword,initial.Thistells you that the correct option is the best starting point for discus- sion about the transfusion therapy. Eliminate the options that have emotionally laden trigger words, including gone into shock and risks, which make them incorrect. From the remaining options,focuson thestrategicword and usetherapeuticcom- munication techniques to direct you to the correct option. Review: Blood transfusion procedures

Aclient receiving a transfusion of packed red blood cells (PRBCs) begins to vomit. The client's blood pressure is 90/50 mm Hg from a baseline of 125/ 78 mm Hg. The client's temperature is 100.8 °F (38.2 °C) orally from a baseline of 99.2 °F (37.3 °C) orally. The nurse determines that the client may be experiencing which complication of a blood transfusion? 1. Septicemia 2. Hyperkalemia 3. Circulatory overload 4. Delayed transfusion reaction

1 Rationale: Septicemia occurs with the transfusion of blood contaminated with microorganisms. Signs include chills, fever, vomiting, diarrhea, hypotension, and the development of shock. Hyperkalemia causes weakness, paresthesias, abdomi- nal cramps, diarrhea, and dysrhythmias. Circulatory overload causes cough, dyspnea, chest pain, wheezing, tachycardia, and hypertension. Adelayed transfusion reaction can occur days to years after a transfusion. Signs include fever, mild jaundice, and a decreased hematocrit level. Test-Taking Strategy: Focus on the subject, a complication of a blood transfusion. Noting that the client's temperature is ele- vated will direct you to the correct option. Review: Complications of blood transfusions

A client requiring surgery is anxious about the possible need for a blood transfusion during or after the procedure. The nurse suggests to the client to take which actions to reduce the risk of possible transfusion complications? Select all that apply. 1. Ask a family member to donate blood ahead of time. 2. Give an autologous blood donation before the surgery. 3. Take iron supplements before surgery to boost hemoglobin levels. 4. Request that any donated blood be screened twice by the blood bank. 5. Take adequate amounts of vitamin C several days prior to the surgery date.

1, 2 Rationale: A donation of the client's own blood before a scheduled procedure is autologous. Donating autologous blood to be reinfused as needed during or after surgery reduces the risk of disease transmission and potential transfusion com- plications. The next most effective way is to ask a family mem- ber to donate blood before surgery. Blood banks do not provide extra screening on request. Preoperative iron supple- ments are helpful for iron deficiency anemia but are not help- ful in replacing blood lost during the surgery. Vitamin C enhances iron absorption, but also is not helpful in replacing blood lost during surgery. Test-Taking Strategy: Focus on the subject, reducing the risk of possible transfusion complications. Recalling that an autol- ogous transfusion is the collection of the client's own blood and also that family donation of blood is usually effective will direct you to the correct options. Review: Blood donation procedures

The nurse who is about to begin a blood transfusion knows that blood cells start to deteriorate after a certain period of time. The nurse takes which actions in order to prevent a complication of the blood transfusion as it relates to deterioration of blood cells? Select all that apply. 1. Checks the expiration date 2. Inspects for the presence of clots 3. Checks the blood group and type 4. Checks the blood identification number 5. Hangs the blood within the specified time frame per agency policy

1, 5 Rationale: The nurse notes the expiration date on the unit of blood to ensure that the blood is fresh. Blood cells begin to deteriorate over time, so safe storage usually is limited to 35 days. Careful notation of the expiration date by the nurse is an essential part of the verification process before hanging a unit of blood. The nurse also needs to hang the blood within the specified time frame after receiving it from the blood bank per agency policy to ensure that the blood being transfused is fresh. The blood bank keeps the blood regulated at a specific temperature, and therefore it must be infused within a specified time frame once received on the unit. The nurse also notes the blood identification (unit) number, blood group and type, and client's name, but this is not specifically related to the degradation of blood cells. The nurse also inspects the unit of blood for leaks, abnormal color, clots, and bubbles and returns the unit to the blood bank if clots are noted. Again, this is not related to the degradation of blood cells over time. Test-Taking Strategy: Focus on the subject, measures to verify prior to blood administration. Note the word deteriorate. To answer this question correctly, you must know which part of the pretransfusion verification procedure relates to the freshness of the unit of blood. Keeping this in mind should direct you to the correct options. Review: Blood transfusion

Following infusion of a unit of packed red blood cells, the client has developed new onset of tachy- cardia, bounding pulses, crackles, and wheezes. Which action should the nurse implement first? 1. Maintain bed rest with legs elevated. 2. Place the client in high-Fowler's position. 3. Increase the rate of infusion of intravenous fluids. 4. Consult with the health care provider (HCP) regarding initiation of oxygen therapy.

2 Rationale: New onset of tachycardia, bounding pulses, and crackles and wheezes posttransfusion is evidence of fluid over- load, a complication associated with blood transfusions. Plac- ing the client in a high-Fowler's (upright) position will facilitate breathing. Measures that increase blood return to the heart, such as leg elevation and administration of IVfluids, should be avoided at this time. In addition, administration of fluids cannot be initiated without a prescription. Consulting with the HCP regarding administration of oxygen may be necessary, but positional changes take a short amount of time to do and should be initiated first. Test-Taking Strategy: Note the strategic word, first. Apply knowledge of signs and symptoms of circulatory overload and use the ABCs—airway, breathing, and circulation—to assist you with selecting the priority action. Remember that placing the client in a high-Fowler's (upright) position will facilitate breathing. Review: Signs of circulatory overload and associated nursing actions

A client has a prescription to receive a unit of packed red blood cells. The nurse should obtain which intravenous (IV) solution from the IV storage area to hang with the blood product at the client's bedside? 1. Lactated Ringer's 2. 0.9% sodium chloride 3. 5% dextrose in 0.9% sodium chloride 4. 5% dextrose in 0.45% sodium chloride

2 Rationale: Sodium chloride 0.9% (normal saline) is a stan- dard isotonic solution used to precede and follow infusion of blood products. Dextrose is not used because it could result in clumping and subsequent hemolysis of red blood cells (RBCs). Lactated Ringer's is not the solution of choice with this procedure. Test-Taking Strategy: Eliminate options that contain dextrose first because they are comparable or alike. From the remain- ing options, remember that normal saline is an isotonic solution and the solution compatible with RBCs. Review: Blood transfusion procedures

The nurse is caring for a client who is receiving a blood transfusion and is complaining of a cough. The nurse checks the client's vital signs, which include temperature of 97.2 °F (36.2 °C), pulse of 108 beats per minute, blood pressure of 152/ 76 mm Hg, respiratory rate of 24 breaths per minute, and an oxygen saturation level of 95% on room air. The client denies pain at this time. Based on this information, what initial action should the nurse take? 1. Collect a urine sample for analysis. 2. Place the client in an upright position. 3. Compare current data to baseline data. 4. Slow the rate of the blood transfusion.

3 Rationale: For the client receiving a blood transfusion, the nurse should monitor for potential complications of a transfu- sion. One of the complications is circulatory overload. Signs and symptoms of circulatory overload include cough, dyspnea, chest pain, wheezing on auscultation of the lungs, headache, hypertension, tachycardia and a bounding pulse, and dis- tended neck veins. Based on the data in the question, the nurse should compare current data to baseline data. The nurse should also further assess the client for other signs and symp- toms of circulatory overload. If the nurse still suspects this complication after comparing to baseline data, the nurse should then place the client in an upright position with the feet in a dependent position and slow the rate of the infusion. Col- lection of a urine sample should occur if the nurse suspects a transfusion reaction, such as a hemolytic reaction. Test-Taking Strategy: Note the strategic word, initial. This word indicates that some or all of the options may be partially or totally correct, but the nurse needs to prioritize. Also, determine if an abnormality exists. Noting that the client is complaining of cough and the vital signs are slightly abnormal should help you to determine that further assessment is needed at this time. Review: Actions to take if a blood transfusion complication is suspected

A client is brought to the emergency department having experienced blood loss related to an arterial laceration. Which blood component should the nurse expect the health care provider to prescribe? 1. Platelets 2. Granulocytes 3. Fresh-frozen plasma 4. Packed red blood cells

3 Rationale: Fresh-frozen plasma is often used for volume expansion as a result of fluid and blood loss. It is rich in clot- ting factors and can be thawed quickly and transfused quickly. Platelets are used to treat thrombocytopenia and platelet dys- function. Granulocytes may be used to treat a client with sepsis or a neutropenic client with an infection that is unresponsive to antibiotics. Packed red blood cells are a blood product used to replace erythrocytes. Test-Taking Strategy: Focus on the subject, the type of trans- fusion therapy for the client experiencing blood loss. Note the relationship between the words experienced blood loss and the word plasma correct option. Review: Fresh-frozen plasma

Packed red blood cells have been prescribed for a female client with a hemoglobin level of 7.6 g/dL (76mmol/L) and a hematocrit level of 30% (0.30). The nurse takes the client's temperature before hanging the blood transfusion and records 100.6 °F (38.1 °C) orally. Which action should the nurse take? 1. Begin the transfusion as prescribed. 2. Administer an antihistamine and begin the transfusion. 3. Delay hanging the blood and notify the health care provider (HCP). 4. Administer 2 tablets of acetaminophen and begin the transfusion.

3 Rationale: If the client has a temperature higher than 100 °F (37.8 °C), the unit of blood should not be hung until the HCP is notified and has the opportunity to give further pre- scriptions. The HCP likely will prescribe that the blood be administered regardless of the temperature, or may instruct the nurse to administer prescribed acetaminophen and wait until the temperature has decreased before administration, but the decision is not within the nurse's scope of practice to make. The nurse needs an HCP's prescription to administer medications to the client. Test-Taking Strategy: Eliminate all options that indicate to begin the transfusion, noting that they are comparable or alike. In addition, the options including antihistamine and acetaminophen indicate administering medication to the cli- ent, which is not done without an HCP's prescription. Review: Nursing responsibilities related to blood transfusion

The nurse determines that a client is having a trans- fusion reaction. After the nurse stops the transfu- sion, which action should be taken next? 1. Remove the intravenous (IV) 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.

3 Rationale: If the nurse suspects a transfusion reaction, the nurse stops the transfusion and infuses normal saline at a keep-vein-open rate pending further health care provider pre- scriptions. 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. Test-Taking Strategy: Note the strategic word, next. Knowing that the IVline should not be removed assists in eliminating the options directing the nurse to discontinue the device. Recalling that normal saline, not dextrose, is used when administering a unit of blood will direct you to the correct option. Review: Transfusion reactions

The nurse has just received a unit of packed red blood cells from the blood bank for transfusion to an assigned client. The nurse is careful to select tubing especially made for blood products, know- ing that this tubing is manufactured with which item? Refer to figures 1-4.

3 Rationale: The tubing used for blood administration has an in- line filter. The filter helps to ensure that any particles larger than the size of the filter are caught in the filter and are not infused into the client. Tinted tubing (option 2) is incorrect because blood does not need to be protected from light. The tubing should be macrodrip, not microdrip (option 4), to allow blood to flow freely through the drip chamber. An air vent (option1) is unnecessary because the blood bag is not made of glass. Test-Taking Strategy: Focus on the subject, intravenous tub- ing used to administer blood. Look at each option carefully and visualize the process of blood administration. Remember that tubing used for blood administration has an in-line filter. Review: Blood administration

The nurse has just received a prescription to trans- fuse a unit of packed red blood cells for an assigned client. What action should the nurse take next? 1. Check a set of vital signs. 2. Order the blood from the blood bank. 3. Obtain Y-site blood administration tubing. 4. Check to be sure that consent for the transfusion has been signed.

4 Rationale: After receiving a prescription for a blood transfu- sion, the first action the nurse should take should be to check to be sure that consent for the transfusion has been signed by the client. If the client has consented, the nurse should then check a set of vital signs to be sure there is no contraindication for a transfusion at that time, such as an elevation in temper- ature. If the vital signs are acceptable, the nurse can then gather supplies to administer the transfusion and order the blood from the blood bank. Test-Taking Strategy: Note the strategic word, next. This word tells you that all options may be partially or totally correct, and you need to choose the best next choice. The nurse should not take any procedural steps until the client has consented to the blood transfusion. Review: Blood transfusions

Aclient with severe blood loss resulting from mul- tiple trauma requires rapid transfusion of several units of blood. The nurse asks another health team member to obtain which device for use during the transfusion procedure to help reduce the risk of cardiac dysrhythmias? 1. Infusion pump 2. Pulse oximeter 3. Cardiac monitor 4. Blood-warming device

4 Rationale: If several units of blood are to be administered rap- idly, a blood warmer should be used. Rapid transfusion of cool blood places the client at risk for cardiac dysrhythmias. To pre- vent this, the nurse warms the blood with a blood-warming device. Pulse oximetry and cardiac monitoring equipment are useful for the early assessment of complications but do not reduce the occurrence of cardiac dysrhythmias. Electronic infusion devices are not helpful in this case because the infu- sion must be rapid, and infusion devices generally are used to control the flow rate. In addition, not all infusion devices are made to handle blood or blood products. Test-Taking Strategy: Note the words rapid and reduce the risk. These words tell you that the blood will infuse quickly and that the correct option is the one that will minimize the risk of car- diac dysrhythmias. Eliminate the pulse oximeter and cardiac monitor first because these items are comparable or alike and are used to assess for rather than reduce the risk of compli- cations. From the remaining options, use knowledge related to the complications of transfusion therapy and note the relation- ship between thewordsseveralunitsofbloodin thequestion and blood-warming device in the correct option. Review: Blood transfusions

A client has received a transfusion of platelets. The nurse evaluates that the client is benefiting mostfrom this therapy if the client exhibits which finding? 1. Increased hematocrit level 2. Increased hemoglobin level 3. Decline of elevated temperature to normal 4. Decreased oozing of blood from puncture sites and gums

4 Rationale: Platelets are necessary for proper blood clotting. The client with insufficient platelets may exhibit frank bleeding or oozing of blood from puncture sites, wounds, and mucous membranes. Increased hemoglobin and hematocrit levels would occur when the client has received a transfusion of red blood cells. An elevated temperature would decline to nor- mal after infusion of granulocytes because these cells were instrumental in fighting infection in the body. Test-Taking Strategy: Use knowledge regarding the potential uses and benefits of the various types of blood product trans- fusions. Eliminate increased hematocrit and increased hemo- globin first because they are comparable or alike. From the remaining options, recalling that platelets are necessary for proper blood clotting will direct you to the correct option. Review: Types of blood products

The nurse, listening to the morning report, learns that an assigned client received a unit of granulocytes the previous evening. The nurse makes a note to assess the results of which daily serum laboratory studies to assess the effectiveness of the transfusion? 1. Hematocrit level 2. Erythrocyte count 3. Hemoglobin level 4. White blood cell count

4 Rationale: The client who has neutropenia may receive a transfusion of granulocytes, or WBCs. These clients often have severe infections and are unresponsive to antibiotic therapy. The nurse notes the results of follow-up WBC counts and differential to evaluate the effectiveness of the therapy. The nurse also continues to monitor the client for signs and symp- toms of infection. Erythrocyte count and hemoglobin and hematocrit levels are determined after transfusion of packed red blood cells. Test-Taking Strategy: Note the strategic word, effectiveness. Recalling that granulocytes are a component of WBCs will assist in directing you to the correct option. In addition, note that the remaining options are comparable or alike in that these options all refer to red blood cells. Review: Types of blood products and granulocytes