NCLEX Review

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.Checks the expiration date 5.Hangs the blood within the specified time frame per agency policy

A client has experienced high blood pressure and crackles in the lungs during previous blood transfusions. The client asks the nurse whether it is safe to receive another transfusion. The nurse explains that which medication most likely will be prescribed before the transfusion is begun? 1.Furosemide 2.Acetaminophen 3.Diphenhydramine 4.Acetylsalicylic acid

1.Furosemide

The nurse has just obtained a unit of blood from the blood bank to transfuse into a client as prescribed. Before preparing the blood for transfusion, the nurse looks for which member of the health care team to assist in checking the unit of blood? 1.Phlebotomist 2.Medical student 3.Registered nurse (RN) 4.Blood bank technician

3.Registered nurse (RN)

The nurse determines that a client is having a transfusion reaction. After the nurse stops the transfusion, 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.Run normal saline at a keep-vein-open rate

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, knowing that this tubing is manufactured with which item? Click on the image to indicate your answer.

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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 a temperature of 97.2º F (36.2º 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.Slow the rate of the blood transfusion. 4.Compare current data to baseline data.

4.Compare current data to baseline data.

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

4.Delay hanging the blood and notify the primary health care provider (PHCP).

The nurse is monitoring a client who is receiving a blood transfusion. After 30 minutes of the infusion, the client begins to have chills and back pain. His temperature is 100.1º F (37.8º C). What action should the nurse take first? 1.Assess the client for other symptoms. 2.Slow the blood transfusion and monitor the client's vital signs. 3.Remind the client that these are expected reactions to a blood transfusion. 4.Discontinue the infusion and start an infusion of normal saline using new tubing.

4.Discontinue the infusion and start an infusion of normal saline using new tubing.

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.White blood cell count

The nurse is picking up a unit of packed red blood cells at the hospital blood bank. After putting the pen down, the nurse glances at the clock, which reads 1300. The nurse calculates that the transfusion must be started by which time? 1.1330 2.1400 3..1430 4.1500

1.1330

A unit of platelets was just received from the blood bank for transfusion to an assigned client. The nurse should select tubing with which feature for the transfusion? 1.An in-line filter 2.At least 3 Y-ports 3.Self-sealing valves 4.Tinted to protect the blood from light

1.An in-line filter

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.Ask a family member to donate blood ahead of time. 2.Give an autologous blood donation before the surgery.

The nurse has discontinued a unit of blood that was infusing into a client because the client experienced a transfusion reaction. After documenting the incident appropriately, the nurse sends the blood bag and tubing to which department? 1.Blood bank 2.Infection control 3.Risk management 4.Environmental services

1.Blood bank

A client 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 100.8º F (38.2º C) orally from a baseline of 99.2º F (37.3º 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.Septicemia

The nurse has obtained a unit of blood from the blood bank and has checked the blood bag properly with another nurse. Just before beginning the transfusion, the nurse should assess which priority item? 1.Vital signs 2.Skin color 3.Urine output 4.Latest hematocrit level

1.Vital signs

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. 0.9% sodium chloride

The nurse is told by a primary health care provider that a client in hypovolemic shock will require plasma expansion. The nurse should prepare which supplies for transfusion? 1.Bag of platelets with filtered tubing 2.Bottle of albumin with vented tubing 3.Cryoprecipitate bag with vented tubing 4.Infusion pump and bag of packed red blood cells

2.Bottle of albumin with vented tubing

Following infusion of a unit of packed red blood cells, the client has developed new onset of tachycardia, 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 primary health care provider (PHCP) regarding initiation of oxygen therapy.

2.Place the client in high-Fowler's position.

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.Bacteremia 2.Hypovolemia 3.Circulatory overload 4.Transfusion reaction

3.Circulatory overload

The nurse overhears a primary health care provider (PHCP) stating that a client diagnosed with disseminated intravascular coagulation (DIC) requires a transfusion. Which blood product should the nurse anticipate that the PHCP will write a prescription for? 1.Albumin 2.Platelets 3.Cryoprecipitate 4.Packed red blood cells

3.Cryoprecipitate

One unit of packed red blood cells has been prescribed for a client with severe anemia. The client has received multiple transfusions in the past, and it is documented that the client has experienced urticaria-type reactions from the transfusions. The nurse anticipates that which medication will be prescribed before administration of the red blood cells to prevent this type of reaction? 1.Ibuprofen 2.Acetaminophen 3.Diphenhydramine 4.Acetylsalicylic acid

3.Diphenhydramine

The nurse enters the room of a client who began receiving a blood transfusion 45 minutes earlier to check on the client. The client is complaining of "itching all over" and has a generalized rash. The client's temperature has not changed from baseline and the lungs are clear to auscultation. Which complication of blood transfusion therapy should the nurse determine that this client is most likely experiencing? 1.Bacteremia 2.Fluid overload 3.Hypovolemic shock 4.Allergic transfusion reaction

4.Allergic transfusion reaction

A client with severe blood loss resulting from multiple 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.Blood-warming device

The nurse has just received a prescription to transfuse 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.Check to be sure that consent for the transfusion has been signed.

A client has received a transfusion of platelets. The nurse evaluates that the client is benefiting most from 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.Decreased oozing of blood from puncture sites and gums