Blood Transfusion

***************************** A 62 year-old newly admitted patient is receiving a blood transfusion for hemorrhagic anemia. Which nursing intervention takes highest priority when caring for this patient ? A. Instructiong the patient to report any itching, chest pain, or dyspnea B. Informing the patient that the transfusion usually takes 4 to 6 hours C. Documenting blood administration in the patient's chart D. Warming the blood prior to transfusion

A

************************* The patient 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 patient? Fill in the blank

Answer: O-

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) Help her into a sitting position with her head lowered below her knees. B) Administer supplementary oxygen by nasal prongs. C) Obtain a full set of vital signs. D) Inform a physician or other primary care provider.

Ans: A Feedback: 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) Have the patient identify his or her blood type in writing. B) Ensure that the patient has granted verbal consent for transfusion. C) Assess the patient's vital signs to establish baselines. D) Facilitate insertion of a central venous catheter.

Ans: C Feedback: 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.

************************** The physician ordered 2 units of packed RBCs to be administered to the patient. At 6AM the night shift nurse started the first unit's transfusion before going off her shift. At 10 AM 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 65% complete. Which of the following nursing actions is most appropriate? A. Document the amount infused this far and continue the transfusion. B. Advise the blood bank about the delay for the next unit C. Discontinue the transfusion. D. Restart another peripheral line with 0.9% NS and restart

C

*************************** A patient has an order to receive a one unit of packed RBC's. The nurse make sure which of the following intravenous solutions to hang with the blood product at the patient's bedside? A. 5% dextrose in 0.9% sodium chloride B. Dextrose in 0.45% sodium chloride C. 0.9% sodium chloride D. Rterm-7ingers lactate

C

***************************** As the nurse you know that there is a risk of a transfusion reaction during the administration of red blood cells. Which of the following patients below is at most risk for a fibrile (non-hemolytic) transfusion reaction? A. A 42 year old female who is immunocompromised B. A 25 year old female who is AB+ and just received B+ blood C. A 78 year old male who is B+ that just received O+ blood during a transfusion D. A 38 year old male who has received multiple blood transfusions in the past year

D

*************************** How long should the nurse stay and monitor the client to ensure a transfusion reaction will not happen? A. 60 minutes B. 45 minutes C. 15 minutes D. 35 minutes

C

The client has a hematocrit of 22.3% and a hemoglobin of 7.7 g/dL. The HCP has ordered two (2) 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.

ANSWER: 1 1. The client must give permission to receive blood or blood products because of the nature of potential complications. 2. Most blood products require at least a 20-gauge IV because of the size of the cells. RBCs are best infused through an 18-gauge IV. If unable to achieve cannulation with an 18-gauge, a 20-gauge is the smallest accept- able IV. Smaller IVs damage the cell walls of the RBCs and reduce the life expectancy of the RBCs. 3. Because infusing IV fluids can cause a fluid volume overload, the nurse must assess for congestive heart failure. Assessing the lungs includes auscultating for crackles and other signs of left-sided heart failure. Additional assessment findings of jugular vein distention, peripheral edema, and liver engorgement indicate right- sided failure. 4. Checking for allergies is important prior to administering any medication. Some medications are administered prior to blood administration. 5. A keep-open IV of 0.9% saline would be hung. D5W causes red blood cells to hemolyze in the tubing.

The client is admitted to the emergency department after a motor-vehicle accident. The nurse notes profuse bleeding from a right-sided abdominal injury. Which intervention should the nurse implement first? 1. Type and crossmatch for red blood cells 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.

ANSWER: 2 1. This should be done, but the client requires the IV first. This client is at risk for shock. 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. 3. The client will probably need to have surgery to correct the source of the bleeding, but sta- bilizing the client with fluid resuscitation is first priority. 4. This is the last thing on this list in order of priority.

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) Administer the platelets as rapidly as the patient can tolerate. B) Establish IV access as soon as the platelets arrive from the blood bank. C) Ensure that the patient has a patent central venous catheter. D) Aspirate 10 to 15 mL of blood from the patient's IV immediately following the transfusion.

Ans: A Feedback: 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.

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) Slow the infusion rate and monitor the patient 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 ordered.

Ans: A Feedback: 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 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) Antibodies to donor leukocytes remained in the blood. B) The donor blood was incompatible with that of the patient. C) The patient had a sensitivity reaction to a plasma protein in the blood. D) The blood was infused too quickly and overwhelmed the patient's circulatory system.

Ans: B Feedback: 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.

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) Apply an icepack to the blood that remains to be infused. B) Discontinue the remainder of the PRBC transfusion and inform the physician. 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 Feedback: 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.

A patient 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 patients with a history of transfusion reactions B) Prevention of viral infections from another person's blood C) Avoidance of complications in patients with alloantibodies D) Prevention of alloimmunization

Ans: B Feedback: The primary advantage of autologous transfusions is the prevention of viral infections from another person's blood. Other secondary advantages include safe transfusion for patients with a history of transfusion reactions, prevention of alloimmunization, and avoidance of complications in patients with alloantibodies.

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) Notify the patient's physician. B) Stop the transfusion immediately. C) Remove the patient's IV access. D) Assess the patient's chest sounds and vital signs.

Ans: B Feedback: 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.

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

Ans: C Feedback: 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 patient lives with a diagnosis of sickle cell anemia and receives frequent blood transfusions. The nurse should recognize the patient's consequent risk of what complication of treatment? A) Hypovolemia B) Vitamin B12 deficiency C) Thrombocytopenia D) Iron overload

Ans: D Feedback: Patients with chronic transfusion requirements can quickly acquire more iron than they can use, leading to iron overload. These individuals are not at risk for hypovolemia and there is no consequent risk for low platelet or vitamin B12 levels.

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/hr. B) Administer prophylactic antihistamines prior to all blood transfusions. C) Establish baseline vital signs for all patients receiving transfusions. D) Be vigilant in identifying the patient and the blood component.

Ans: D Feedback: 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.

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) "All the donated blood in the United States is treated with antiretroviral medications before it is used." B) "That did happen in some high-profile cases in the twentieth century, but it is no longer a possibility." C) "HIV was eradicated from the US blood supply in the early 2000s." D) "The chances of contracting AIDS from a blood transfusion in the United States are exceedingly low."

Ans: D Feedback: 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.

***************************** The nurse is planning for the administration of 2 units of packed red blood cells (PRBC) to a 84-year-old patient with a history of heart failure and peptic ulcers. Which of the following orders does the nurse expect to be ordered for this patient? A. Administer diphenhydramine prior to transfusion B. Transfuse both units over a total period of 3 hours C. Administer furosemide between transfusion D. Draw blood for PT, PTT immediately after transfusion

C