chp 38 (blood transfusion)

28. A nurse at a blood donation clinic has completed the collection of blood from a client. The client reports feeling "light-headed" and appears pale. Which action by the nurse is most appropriate? A. Help the client to sit, with head lowered below knees. B. Administer supplementary oxygen by nasal prongs. C. Obtain a full set of vital signs. D. Inform a health care provider or other primary care provider.

ANS: A Rationale: A donor who appears pale or complains of faintness should immediately lie down or sit with the head lowered below the knees. The client should be observed for another 30 minutes. There is no immediate need for a health care provider's care. Supplementary oxygen may be beneficial, but may take too much time to facilitate before a syncopal episode. Repositioning must precede assessment of vital signs. PTS: 1 REF: p. 898 NAT: Client Needs: Safe, Effective Care Environment: Safety and Infection Control TOP: Chapter 28: Assessment of Hematologic Function and Treatment Modalities KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply NOT: Multiple Choice

34. A client is receiving a blood transfusion and reports a new onset of slight dyspnea. The nurse's rapid assessment reveals bilateral lung crackles and elevated BP. What is the nurse's most appropriate action? A. Slow the infusion rate and monitor the client closely. B. Discontinue the transfusion and begin resuscitation. C. Pause the transfusion and administer a 250 mL bolus of normal saline. D. Discontinue the transfusion and administer a beta-blocker, as prescribed.

ANS: A Rationale: The client is showing early signs of hypervolemia; the nurse should slow the infusion rate and assess the client closely for any signs of exacerbation. At this stage, discontinuing the transfusion is not necessary. A bolus would worsen the client's fluid overload. PTS: 1 REF: p. 904 NAT: Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies TOP: Chapter 28: Assessment of Hematologic Function and Treatment Modalities KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply NOT: Multiple Choice

15. An older adult client is exhibiting many of the characteristic signs and symptoms of iron deficiency. In addition to a complete blood count, what diagnostic assessment should the nurse anticipate? A. Stool for occult blood B. Bone marrow biopsy C. Lumbar puncture D. Urinalysis

ANS: A Rationale: Iron deficiency in the adult generally indicates blood loss (e.g., from bleeding in the GI tract or heavy menstrual flow). Bleeding in the GI tract can be preliminarily identified by testing stool for the presence of blood. A bone marrow biopsy would not be undertaken for the sole purpose of investigating an iron deficiency. Lumbar puncture and urinalysis would not be clinically relevant. PTS: 1 REF: p. 888 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 28: Assessment of Hematologic Function and Treatment Modalities KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply NOT: Multiple Choice

32. A client is being treated in the ICU after a medical error resulted in an acute hemolytic transfusion reaction. What was the etiology of this client's adverse reaction? A. Antibodies to donor leukocytes remained in the blood. B. The donor blood was incompatible with that of the client. C. The client had a sensitivity reaction to a plasma protein in the blood. D. The blood was infused too quickly and overwhelmed the client's circulatory system.

ANS: B Rationale: An acute hemolytic reaction occurs when the donor blood is incompatible with that of the recipient. In the case of a febrile nonhemolytic reaction, antibodies to donor leukocytes remain in the unit of blood or blood component. An allergic reaction is a sensitivity reaction to a plasma protein within the blood component. Hypervolemia does not cause an acute hemolytic reaction. PTS: 1 REF: p. 901 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 28: Assessment of Hematologic Function and Treatment Modalities KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Analyze NOT: Multiple Choice

30. A client on the medical unit is receiving a unit of packed red blood cells (PRBCs). Difficult intravenous (IV) access has necessitated a slow infusion rate, and the nurse notes that the infusion began 4 hours ago. Which action by the nurse is the most appropriate? A. Apply an icepack to the blood that remains to be infused. B. Discontinue the remainder of the PRBC transfusion, and inform the health care provider. C. Disconnect the bag of PRBCs, cool for 30 minutes, and then administer. D. Administer the remaining PRBCs by the IV direct (IV push) route.

ANS: B Rationale: Because of the risk of increased bacterial proliferation in the PRBCs and subsequent infection in the client, a PRBC transfusion should not exceed 4 hours. Remaining blood should not be transfused, even if it is cooled. Blood is not administered by the IV direct route. PTS: 1 REF: p. 901 NAT: Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies TOP: Chapter 28: Assessment of Hematologic Function and Treatment Modalities KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply NOT: Multiple Choice

16. A client is being treated for the effects of a longstanding vitamin B12 deficiency. Which aspect of the client's health history would most likely predispose the client to this deficiency? A. The client has irregular menstrual periods. B. The client is a vegan. C. The client donated blood 60 days ago. D. The client frequently smokes marijuana.

ANS: B Rationale: Because vitamin B12 is found only in foods of animal origin, vegans may ingest little vitamin B12. Irregular menstrual periods, marijuana use, and blood donation would not precipitate a vitamin B12 deficiency. PTS: 1 REF: p. 888 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 28: Assessment of Hematologic Function and Treatment Modalities KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply NOT: Multiple Choice

27. A nurse has participated in organizing a blood donation drive at a local community center. Which client would most likely be disallowed from donating blood? A. A client who is 81 years of age B. A client whose blood pressure is 78/49 mm Hg C. A client who donated blood 4 months ago D. A client who has type 1 diabetes

ANS: B Rationale: For potential blood donors, systolic arterial blood pressure should be 80 to 180 mm Hg, and the diastolic pressure should be 50 to 100 mm Hg. There is no absolute upper age limit. Donation 4 months ago does not preclude safe repeat donation (donors are only required to wait at least 8 weeks between donations), and diabetes is not a contraindication. PTS: 1 REF: p. 897 NAT: Client Needs: Safe, Effective Care Environment: Management of Care TOP: Chapter 28: Assessment of Hematologic Function and Treatment Modalities KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze NOT: Multiple Choice

13. The nurse is describing normal erythrocyte physiology to a client who has a diagnosis of anemia. The nurse should explain that the erythrocytes consist primarily of which substance? A. Plasminogen B. Hemoglobin C. Hematocrit D. Fibrin

ANS: B Rationale: Mature erythrocytes consist primarily of hemoglobin, which contains iron and makes up 95% of the cell mass. Erythrocytes are not made of fibrin or plasminogen. Hematocrit is a measure of erythrocyte volume in whole blood. PTS: 1 REF: p. 887 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 28: Assessment of Hematologic Function and Treatment Modalities KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Understand NOT: Multiple Choice

36. A client is receiving the first of two prescribed units of PRBCs. Shortly after the initiation of the transfusion, the client reports chills and experiences a sharp increase in temperature. What is the nurse's priority action? A. Position the client in high Fowler position B. Discontinue the transfusion. C. Auscultate the client's lungs. D. Obtain a blood specimen from the client.

ANS: B Rationale: Stopping the transfusion is the first step in any suspected transfusion reaction. This must precede other assessments and interventions, including repositioning, chest auscultation, and collecting specimens. PTS: 1 REF: p. 903 NAT: Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies TOP: Chapter 28: Assessment of Hematologic Function and Treatment Modalities KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply NOT: Multiple Choice

11. A client undergoing a hip replacement has autologous blood on standby if a transfusion is needed. What is the primary advantage of autologous transfusions? A. Safe transfusion for clients with a history of transfusion reactions B. Prevention of viral infections from another person's blood C. Avoidance of complications in clients with alloantibodies D. Prevention of alloimmunization

ANS: B Rationale: The primary advantage of autologous transfusions is the prevention of viral infections from another person's blood. Other secondary advantages include safe transfusion for clients with a history of transfusion reactions, prevention of alloimmunization, and avoidance of complications in clients with alloantibodies. PTS: 1 REF: p. 898 NAT: Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies TOP: Chapter 28: Assessment of Hematologic Function and Treatment Modalities KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze NOT: Multiple Choice

6. The nurse caring for a client receiving a transfusion notes that 15 minutes after the infusion of packed red blood cells (PRBCs) has begun, the client is having difficulty breathing and reports severe chest tightness. What is the most appropriate initial action for the nurse to take? A. Notify the client's health care provider. B. Stop the transfusion immediately. C. Remove the client's IV access. D. Assess the client's chest sounds and vital signs.

ANS: B Rationale: Vascular collapse, bronchospasm, laryngeal edema, shock, fever, chills, and jugular vein distension are severe reactions. The nurse should discontinue the transfusion immediately, monitor the client's vital signs, and notify the health care provider. The blood container and tubing should be sent to the blood bank. A blood and urine specimen may be needed if a transfusion reaction or a bacterial infection is suspected. The client's IV access should not be removed. PTS: 1 REF: p. 906 NAT: Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies TOP: Chapter 28: Assessment of Hematologic Function and Treatment Modalities KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply NOT: Multiple Choice

39. Which of the following circumstances would most clearly warrant autologous blood donation? A. The client has type-O blood. B. The client has sickle cell disease or a thalassemia. C. The client has elective surgery pending. D. The client has hepatitis C.

ANS: C Rationale: Autologous blood donation is useful for many elective surgeries where the potential need for transfusion is high. Type-O blood, hepatitis, sickle cell disease, and thalassemia are not clear indications for autologous donation. PTS: 1 REF: p. 898 NAT: Client Needs: Safe, Effective Care Environment: Management of Care | Client Needs: Physiological Integrity: Basic Care and Comfort TOP: Chapter 28: Assessment of Hematologic Function and Treatment Modalities KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand NOT: Multiple Choice

29. A client's low hemoglobin level has necessitated transfusion of packed red blood cells. Prior to administration, which action should the nurse perform? A. Have the client identify the blood type in writing. B. Ensure that the client has granted verbal consent for transfusion. C. Assess the client's vital signs to establish baselines. D. Facilitate insertion of a central venous catheter.

ANS: C Rationale: Prior to a transfusion, the nurse must take the client's temperature, pulse, respiration, and blood pressure to establish a baseline. Written consent is required, and the client's blood type is determined by type and cross match, not by the client's self-declaration. Peripheral venous access is sufficient for blood transfusion. PTS: 1 REF: p. 900 NAT: Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies TOP: Chapter 28: Assessment of Hematologic Function and Treatment Modalities KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply NOT: Multiple Choice

3. A client has come to the OB/GYN clinic due to recent heavy menstrual flow. Because of the client's consequent increase in red cell production, the nurse should recommend the client increase daily intake of what substance? A. Vitamin E B. Vitamin D C. Iron D. Magnesium

ANS: C Rationale: To replace blood loss, the rate of red cell production increases. Iron is incorporated into hemoglobin. Vitamins E and D and magnesium do not need to be increased when RBC production is increased. PTS: 1 REF: p. 888 NAT: Client Needs: Physiological Integrity: Basic Care and Comfort TOP: Chapter 28: Assessment of Hematologic Function and Treatment Modalities KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply NOT: Multiple Choice

31. Two units of packed red blood cells have been prescribed for a client who has experienced a gastrointestinal bleed. The client is highly reluctant to receive a transfusion, stating, "I'm terrified of getting acquired immunodeficiency syndrome (AIDS) from a blood transfusion." How can the nurse best address the client's concerns? A. "All donated blood is treated with antiretroviral medications before it is used." B. "That did happen in some high-profile cases in the 20th century, but it is no longer a possibility." C. "HIV was eradicated from the blood supply in the early 2000s." D. "Donated blood is screened for human immunodeficiency virus (HIV), and the risk of contraction is very low."

ANS: D Rationale: The client can be reassured about the very low possibility of contracting HIV from the transfusion. However, it is not an absolute impossibility. Antiretroviral medications are not introduced into donated blood. The blood supply is constantly dynamic, due to the brief life of donated blood. PTS: 1 REF: p. 905 NAT: Client Needs: Psychosocial Integrity TOP: Chapter 28: Assessment of Hematologic Function and Treatment Modalities KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply NOT: Multiple Choice

33. An interdisciplinary team has been commissioned to create policies and procedures aimed at preventing acute hemolytic transfusion reactions. What action has the greatest potential to reduce the risk of this transfusion reaction? A. Ensure that blood components are never infused at a rate greater than 125 mL/h. B. Administer prophylactic antihistamines prior to all blood transfusions. C. Establish baseline vital signs for all clients receiving transfusions. D. Be vigilant in identifying the client and the blood component.

ANS: D Rationale: The most common causes of acute hemolytic reaction are errors in blood component labeling and client identification that result in the administration of an ABO-incompatible transfusion. Actions to address these causes are necessary in all health care settings. Prophylactic antihistamines are not normally given, and would not prevent acute hemolytic reactions. Similarly, baseline vital signs and slow administration will not prevent this reaction. PTS: 1 REF: p. 901 NAT: Client Needs: Safe, Effective Care Environment: Safety and Infection Control TOP: Chapter 28: Assessment of Hematologic Function and Treatment Modalities KEY: Integrated Process: Communication and Documentation BLM: Cognitive Level: Apply NOT: Multiple Choice

4. The nurse is planning the care of a client with a nutritional deficit and a diagnosis of megaloblastic anemia. The nurse should recognize that this client's health problem is due to which issue with the red blood cells (RBCs)? A. Production of inadequate quantities of RBCs B. Premature release of immature RBCs C. Injury to the RBCs in circulation D. Abnormalities in the structure and function of RBCs

ANS: D Rationale: Vitamin B12 and folate deficiencies are characterized by the production of abnormally large erythrocytes called megaloblasts. Because these cells are abnormal, many are sequestered (trapped) while still in the bone marrow, and their rate of release is decreased. Some of these cells actually die in the marrow before they can be released into the circulation. This results in megaloblastic anemia. This pathologic process does not involve inadequate production, premature release, or injury to existing RBCs. PTS: 1 REF: p. 888 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 28: Assessment of Hematologic Function and Treatment Modalities KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply NOT: Multiple Choice