Canvas Quiz: Gastrointestinal (GI) Bleed

A nurse is preparing to administer a transfusion of RBCs to a client who has heart failure. For which of the following manifestations should the nurse monitor to prevent fluid volume overload? (Select all that apply.) - Confusion - Gastrointestinal bloating - Jugular vein distention - Hypotension - Dyspnea

- Confusion - Dyspnea - Jugular vein distention General feedback: Dyspnea is correct. Dyspnea is a clinical manifestation of fluid volume overload.Gastrointestinal bloating is incorrect. Gastrointestinal bloating is not a clinical manifestation of heart failure.Jugular vein distention is correct. Jugular vein distention is a clinical manifestation of fluid volume overload.Confusion is correct. Confusion is a clinical manifestation of fluid volume overload.Hypotension is incorrect.Hypertension, not hypotension, is a clinical manifestation of fluid volume overload. Hypotension is a manifestation of a hemolytic transfusion reaction. (ATI Pharmacology Test Bank)

A nurse is preparing to administer blood to a client. The unit of blood on hand is type O negative, and the client has type A positive blood. Which of the following actions should the nurse take? a) administer the blood as ordered b) complete an incident report c) notify the blood bank d) contact the provider for further orders

a) administer the blood as ordered General feedback: Type O negative blood is the universal donor blood and should be administered as ordered (ATI Pharmacology Test Bank).

A nurse is reviewing a client's laboratory results and finds the hemoglobin in 10 g/dL and the hematocrit is 30%. The nurse recognizes that the client is at risk for which of the following? a) cellular hypoxia b) impaired immunity c) fluid retention d) prolonged bleeding

a) cellular hypoxia General feedback: The client's laboratory results indicate anemia, which places the client at risk for cellular hypoxia. The client's laboratory results indicate anemia, Increased serum sodium, rather than anemia, places the client at risk for fluid retention. The client's laboratory results indicate anemia. Leukopenia, rather than anemia, places the client at risk for impaired immunity. The client's laboratory results indicate anemia. Thrombocytopenia, rather than anemia, places the client at risk for prolonged bleeding (ATI Pharmacology Test Bank).

A nurse suspects anaphylaxis when caring for a client following the administration of a blood product. Which of the following should be the nurse's priority intervention? a) count the respiratory rate b) prepare equipment for intubation c) administer oxygen d) insert an IV line

a) count the respiratory rate General feedback: Checking the clients respiratory status is the priority action when following the nursing process approach to care. The nurse should already have an established IV for fluids and medications. The nurse should administer oxygen to the client using a high-flow, non-rebreather mask to prevent hypoxia. However this is not the priority. Preparing equipment for intubation ensures the client will maintain an open airway in the event of respiratory failure. However it is not the priority (ATI Pharmacology Test Bank).

A charge nurse is supervising a newly licensed nurse caring for a client who is receiving a transfusion of packed RBC. The nurse suspects a possible hemolytic reaction. After stopping the blood transfusion, which of the following actions by the new nurse requires intervention by the charge nurse? a) the nurse sends a blood specimen to the laboratory b) the nurse starts the transfusion of another unit of blood product c) the nurse initiates an infusion of 0.9% sodium chloride d) the nurse collects a urine specimen

b) the nurse starts the transfusion of another unit of blood product General feedback: When the nurse suspects a hemolytic reaction, the RN should immediately stop the transfusion of all blood products. When the nurse suspects a hemolytic reaction an IV should be established, 0.9% NS should be administered, a urine specimen should be collected to assess for the presence of hemoglobin in the urine, and a blood specimen should be collected and sent to the lab for analysis (ATI Pharmacology Test Bank).

A nurse is preparing to transfuse one unit of packed RBC to a client who experienced a mild allergic reaction during a previous transfusion. The nurse should administer diphenydramine prior to the transfusion for which of the following allergic responses? a) fluid overload b) hemolysis c) fever d) urticaria

d) urticaria General feedback: For clients who have previously had allergic reactions to blood transfusions, administering an antihistamine such as diphenhydramine prior to the transfusion might prevent future reactions. Allergic reactions typically include urticaria (hives). An antihistamine will not prevent a febrile, non-hemolytic reaction to a blood transfusion. A possible preventative measure is transfusing leukocyte-poor blood products to avoid sensitization to the donor's WBC. An antihistamine will not prevent fluid overload. Transfusing the blood product slowly and not exceeding the volume that is necessary can reduce this risk. An antihistamine will not prevent hemolysis, which results from incompatibility between the donor and the recipient (ATI Pharmacology Test Bank).

A nurse is monitoring a client who reports having chills and back pain during a blood transfusion. Which of the following actions is the nurse's priority? a) assessing the client's skin for a rash b) covering the client with a blanket c) stopping the transfusion d) notifying the provider

c) stopping the transfusion General feedback: The greatest risk for the patient is r/t injury from transfusion reaction which is indicated by chills and back pain. The nurse should cover the client with a blanket but, this is not the priority. The nurse should notify the provider but, this is not the priority. The nurse should ass the client for a rash but, this is not the priority (ATI Pharmacology Test Bank).

A nurse is caring for a client who has gastrointestinal bleeding. Which of the following actions should the nurse take first? a) administer pain medication b) explain the procedure for an upper gastrointestinal series c) test the client's emesis for blood d) assess orthostatic blood pressure

d) assess orthostatic blood pressure General feedback: Assessing orthostatic BP will assist the nurse in determining if the client is hypovolemic. The nurse should teach the client about testing but, this is not the priority. The nurse should administer pain medications but, this is not the priority. The nurse should test the client's emesis for blood, but, this is not the priority (ATI Pharmacology Test Bank).

A nurse is caring for a client who has an active upper gastrointestinal bleed. After inserting a NG tube into the client, which of the following findings should the nurse anticipate? a) dark amber drainage b) frothy pink drainage c) greenish-yellow drainage d) coffee-ground drainage

d) coffee-ground drainage General feedback: "Coffee-ground" drainage or emesis indicates the presence of blood. The coffee ground appearance is the result of the effects of methemoglobin on the hemoglobin. Frothy pink drainage from the NG tube indicates incorrect tube placement. Dark amber drainage indicates the presence of bile and is seen in clients who have gallbladder or bile duct problems. NG drainage that is greenish-yellow d/t bile is an expected finding from a typical NG tube (ATI Pharmacology Test Bank).

A nurse is planning to perform a blood transfusion for a client. Which of the following actions should the nurse plan to take? (Select all that apply.) - Prime the blood tubing with dextrose 5% in water - Check the vital signs before transfusion - Check the expiration date of the blood product with a second nurse - Insert an IV with a 18-gauge needle - Transfuse the blood product within 5 hr after removing it from the refrigeration

- Check the vital signs before transfusion - Check the expiration date of the blood product with a second nurse - Insert an IV with a 18-gauge needle General feedback: Check vital signs before transfusion is correct. The nurse should check the client's vital signs immediately before starting the transfusion to create a baseline in order to assess a change in the vital signs during the transfusion.Insert an IV with a 19-gauge needle is correct. The nurse should insert a large bore IV to transfuse the blood easily.Prime the blood tubing with dextrose 5% in water is incorrect. The nurse should prime the blood tubing with 0.9% sodium chloride to reduce the risk for hemolysis.Transfuse the blood product within 5 hr after removing it from refrigeration is incorrect. The nurse should transfuse the blood product within 4 hr after removing it from the refrigerator to reduce the risk for a transfusion reaction.Check the expiration date of the blood product with a second nurse is correct. The expiration date, the client's name, the hospital number, and the blood compatibility are checked with two nurses to reduce the risk for a transfusion reaction. (ATI Pharmacology Test Bank).