Blood Administration Quiz
A patient on the medical unit is receiving a unit of PRBCs. Difficult IV access has necessitated a slow infusion rate and the nurse notes that the infusion began 4 hours ago. What is the nurse's most appropriate action? A. Discontinue the remainder of the PRBC transfusion and inform the physician. B. Administer the remaining PRBCs by the IV direct (IV push) route. C. Disconnect the bag of PRBCs, cool for 30 minutes and then administer. D. Apply an icepack to the blood that remains to be infused.
.A. Discontinue the remainder of the PRBC transfusion and inform the physician. Because of the risk of infection, 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.
Two units of PRBCs have been ordered for a patient who has experienced a GI bleed. The patient is highly reluctant to receive a transfusion, stating, "I'm terrified of getting AIDS from a blood transfusion." How can the nurse best address the patient's concerns? A. "The chances of contracting AIDS from a blood transfusion in the United States are exceedingly low." B. "HIV was eradicated from the US blood supply in the early 2000s." C. "All the donated blood in the United States is treated with antiretroviral medications before it is used." D. "That did happen in some high-profile cases in the twentieth century, but it is no longer a possibility."
A. "The chances of contracting AIDS from a blood transfusion in the United States are exceedingly low." The patient 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.
A patient is receiving a blood transfusion and complains of 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. Discontinue the transfusion and administer a beta-blocker, as ordered. B. Slow the infusion rate and monitor the patient closely. C. Discontinue the transfusion and begin resuscitation. D. Pause the transfusion and administer a 250 mL bolus of normal saline
B. Slow the infusion rate and monitor the patient closely. The patient is showing early signs of hypervolemia; the nurse should slow the infusion rate and assess the patient closely for any signs of exacerbation. At this stage, discontinuing the transfusion is not necessary. A bolus would worsen the patient's fluid overload.
A patient is receiving the first of two ordered units of PRBCs. Shortly after the initiation of the transfusion, the patient complains of chills and experiences a sharp increase in temperature. What is the nurse's priority action? A. Discontinue the transfusion. B. Auscultate the patient's lungs. C. Position the patient in high Fowler's. D. Obtain a blood specimen from the patient.
A. Discontinue the transfusion. 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.
A patient is being treated in the ICU after a medical error resulted in an acute hemolytic transfusion reaction. What was the etiology of this patient's adverse reaction? A. The donor blood was incompatible with that of the patient. B. The blood was infused too quickly and overwhelmed the patient's circulatory system. C. Antibodies to donor leukocytes remained in the blood. D. The patient had a sensitivity reaction to a plasma protein in the blood.
A. The donor blood was incompatible with that of the patient. 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.
The nurse is preparing to administer a unit of platelets to an adult patient. When administering this blood product, which of the following actions should the nurse perform? A. Aspirate 10 to 15 mL of blood from the patient's IV immediately following the transfusion. B. Administer the platelets as rapidly as the patient can tolerate. C. Ensure that the patient has a patent central venous catheter. D. Establish IV access as soon as the platelets arrive from the blood bank.
B. Administer the platelets as rapidly as the patient can tolerate. The nurse should infuse each unit of platelets as fast as patient can tolerate to diminish platelet clumping during administration. IV access should be established prior to obtaining the platelets from the blood bank. A central line is appropriate for administration, but peripheral IV access (22-gauge or larger) is sufficient. There is no need to aspirate after the transfusion.
Which of the following circumstances would most clearly warrant autologous blood donation? A. The patient has sickle cell disease or a thalessemia. B. The patient has elective surgery pending. C. The patient has hepatitis C. D. The patient has type-O blood.
B. The patient has elective surgery pending. 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.
A nurse has participated in organizing a blood donation drive at a local community center. Which of the following individuals would most likely be disallowed from donating blood? A. A man who donated blood 4 months ago B. A man who is 81 years of age C. A woman whose blood pressure is 88/51 mm Hg D. A woman who has type 1 diabetes
C. A woman whose blood pressure is 88/51 mm Hg For potential blood donors, systolic arterial BP should be 90 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 and diabetes is not a contraindication.
A nurse at a blood donation clinic has completed the collection of blood from a woman. The woman states that she feels "lightheaded" and she appears visibly pale. What is the nurse's most appropriate action? A. Obtain a full set of vital signs. B. Administer supplementary oxygen by nasal prongs. C. Help her into a sitting position with her head lowered below her knees. D. Inform a physician or other primary care provider.
C. Help her into a sitting position with her head lowered below her knees. A donor who appears pale or complains of faintness should immediately lie down or sit with the head lowered below the knees. He or she should be observed for another 30 minutes. There is no immediate need for a physician'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.
A patient's low hemoglobin level has necessitated transfusion of PRBCs. Prior to administration, what action should the nurse perform? A. Facilitate insertion of a central venous catheter. B. Have the patient identify his or her blood type in writing. C. Ensure that the patient has granted verbal consent for transfusion. D. Assess the patient's vital signs to establish baselines.
D. Assess the patient's vital signs to establish baselines. Prior to a transfusion, the nurse must take the patient's temperature, pulse, respiration, and BP to establish a baseline. Written consent is required and the patient's blood type is determined by type and cross match, not by the patient's self-declaration. Peripheral venous access is sufficient for blood transfusion.
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. Administer prophylactic antihistamines prior to all blood transfusions. B. Establish baseline vital signs for all patients receiving transfusions. C. Ensure that blood components are never infused at a rate greater than 125 mL/hr. D. Be vigilant in identifying the patient and the blood component.
D. Be vigilant in identifying the patient and the blood component. The most common causes of acute hemolytic reaction are errors in blood component labeling and patient 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 administered, and would not prevent acute hemolytic reactions. Similarly, baseline vital signs and slow administration will not prevent this reaction.
The nurse caring for a patient receiving a transfusion notes that 15 minutes after the infusion of packed red blood cells (PRBCs) has begun, the patient is having difficulty breathing and complains of severe chest tightness. What is the most appropriate initial action for the nurse to take? A. Assess the patient's chest sounds and vital signs. B. Notify the patient's physician. C. Remove the patient's IV access. D. Stop the transfusion immediately.
D. Stop the transfusion immediately. Vascular collapse, bronchospasm, laryngeal edema, shock, fever, chills, and jugular vein distension are severe reactions. The nurse should discontinue the transfusion immediately, monitor the patient's vital signs, and notify the physician. 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 patient's IV access should not be removed.
