chapter 32 continued

A patient will need a blood transfusion for the replacement of blood loss from the gastrointestinal tract. The patient states, "That stuff isn't safe!" What is the best response from the nurse?

"I understand your concern. The blood is carefully screened but is not completely risk free."

what are the minimal requirements for blood donors?

- Body weight should be at least 50 kg (110 lb) for a standard 450-mL donation. - People younger than 17 years require parental consent in some states. - The oral temperature should not exceed 37.5°C (99.6°F). - The systolic arterial blood pressure should be 80 to 180 mm Hg, and the - diastolic pressure should be 50 to 100 mm Hg. - The hemoglobin level should be at least 12.5 g/dL.

during transfusion of packed red blood cells, For the first __ minutes, run the transfusion slowly—no faster than _ mL/min. Observe patient carefully for adverse effects. If no adverse effects occur during the first 15 minutes, increase the flow rate unless patient is at high risk for ____________ __________.

15; 5; circulatory overload

Which blood cell type is matched correctly with its function? 1.) T lymphocyte: Humoral immunity 2.) Plasma cell: Cell-mediated immunity 3.) Leukocyte: Fights infection 4.) B lymphocyte: Secretes immunoglobulin

3.) Leukocyte: Fights infection

for transfusion of packed red blood cells, make sure that PRBC transfusion is initiated within __ minutes after removal of PRBCs from blood bank refrigerator

30

A client with Hodgkin disease had a bone marrow biopsy yesterday and reports aching at the biopsy site, rated a 5 (on a 1-10 scale). After assessing the biopsy site, which nursing intervention is most appropriate?

Administer acetaminophen 500 mg po, as ordered (Warm tub baths and a mild analgesic agent (e.g., acetaminophen) may be useful. Aspirin-containing analgesic agents should be avoided it the immediate post-procedure period because they can aggravate or potentiate bleeding.)

The physician performs a bone marrow biopsy from the posterior iliac crest on a client with pancytopenia. What intervention should the nurse perform after the procedure?

Apply pressure over the site for 5-7 minutes

A client in end-stage renal disease is prescribed epoetin alfa and oral iron supplements. Before administering the next dose of epoetin alfa and oral iron supplement, what is the priority action taken by the nurse?

Assesses the hemoglobin level

The nurse should be alert to which adverse assessment finding when transfusing a unit of packed red blood cells (PRBCs) too rapidly?

Crackles auscultated bilaterally (Increasing the flow rate of a blood transfusion too rapidly can result in circulatory overload. Fluid overload can be manifested by crackles in the lungs.)

A thin client is prescribed iron dextran intramuscularly. What is most important action taken by the nurse when administering this medication?

Employs the Z-track technique

A client receiving a blood transfusion reports shortness of breath, appears anxious, and has a pulse of 125 beats/minute. What is the best action for the nurse to take after stopping the transfusion and awaiting further instruction from the health care provider?

Ensure there is an oxygen delivery device at the bedside

A client wants to donate blood before his or her abdominal surgery next week. What should be the nurse's first action?

Explain the time frame needed for autologous donation; Preoperative donations are ideally collected 4 to 6 weeks before surgery; Phlebotomies are not performed within 72 hours of surgery

when transfusing packed red blood cells, what would gas bubbles and unusual color or cloudiness indicate

Gas bubbles may indicate bacterial growth. Abnormal color or cloudiness may be a sign of hemolysis.

A nurse is caring for a patient who has had a bone marrow aspiration with biopsy. What complication should the nurse be aware of and monitor the patient for?

Hemorrhage

Which cell of hematopoiesis is responsible for the production of red blood cells (RBCs) and platelets?

Myeloid stem cell

The nurse obtains a unit of blood for the client, Donald D. Smith. The name on the label on the unit of blood reads Donald A. Smith. All the other identifiers are correct. What action should the nurse take?

Refuse to administer the blood

The nurse is administering a blood transfusion to a client over 4 hours. After 2 hours, the client reports chills and has a fever of 101°F, an increase from a previous temperature of 99.2°F. What does the nurse recognize is occurring with this client?

The client is having a febrile nonhemolytic reaction.

While caring for a client, the nurse notes petechiae on the client's trunk and lower extremities. What precaution will the nurse take when caring for this client?

Use an electric razor when assisting client with shaving. (Petechiae are associated with severe thrombocytopenia, placing the client at risk for bleeding. The nurse should use an electric razor when assisting the client with shaving.)

The client is to receive a unit of packed red blood cells. What is the nurse's first action?

Verify that the client has signed a written consent form.

during transfusion of packed red blood cells how often should the tubing be changed?

after every 2 units transfused to decrease chance of bacterial contamination.

The nurse is screening donors for blood donation. Which client is an acceptable donor for blood? a.) Received a blood transfusion within 1 year b.) Reports having a cold 1 month ago that resolved quickly c.) Had a dental extraction 2 days ago for caries in a tooth d.) Has a history of viral hepatitis as a teenager 10 years ago

b.) Reports having a cold 1 month ago that resolved quickly

Which is a symptom of severe thrombocytopenia? a.) Inflammation of the tongue b.) Inflammation of the mouth c.) Dyspnea d.) Petechiae

d.) Petechiae

Vitamin B and folic acid deficiencies are characterized by production of abnormally large erythrocytes called

megaloblasts.

A blood transfusion of packed red blood cells should not exceed how many hours, and why?

4 hours, because of increased risk for bacterial growth

A client with a history of congestive heart failure has an order to receive 1 unit of packed red blood cells (RBCs). If the nurse hangs the blood at 12:00 pm, by what time must the infusion be completed?

4:00 pm

A client with a history of sickle cell anemia has developed iron overload from repeated blood transfusions. What treatment does the nurse anticipate will be prescribed?

Chelation therapy

Albumin is important for the maintenance of fluid balance within the vascular system. Albumin is produced by which organ?

liver

Which client is not a candidate for blood donation according to the American Heart Association? a.) 18 year old male weighing 52 kg. b.) 86 year old male with blood pressure 110/70 mmHg c.) 26 year old female with hemoglobin 11.0 g/dL d.) 50 year old female with pulse 95 beats/minute

26 year old female with hemoglobin 11.0 g/dL (hemoglobin level should be at least 12.5 g/dL for women)

during transfusion of packed red blood cells, the patient should be monitored closely for 15-30 minutes. Should any adverse reaction occur, stop infusion immediately, notify primary provider, and follow the agency's transfusion reaction standard. what are some adverse effects?

including restlessness, hives, nausea, vomiting, torso or back pain, shortness of breath, flushing, hematuria, fever, or chills.

Never add _________ to blood or blood products; if blood is too thick to run freely, _______ ______ may be added to the unit. If blood must be warmed, use an __-_____ blood warmer with a monitoring system.

medications; normal saline; in-line

The nurse expects which assessment finding of the oral cavity when the client is diagnosed with pernicious anemia?

Smooth tongue

A patient who has long-term packed RBC (PRBC) transfusions has developed symptoms of iron toxicity that affect liver function. What immediate treatment should the nurse anticipate preparing the patient for that can help prevent organ damage?

Iron chelation therapy

The nurse is preparing a patient for a bone marrow aspiration and biopsy from the site of the posterior superior iliac crest. What position will the nurse place the patient in?

Lateral position with one leg flexed

A nurse cares for several mothers and babies in the postpartum unit. Which mother does the nurse recognize as being most at risk for a febrile nonhemolytic reaction?

Rh-negative mother; Rh-positive child

The health care provider believes that the client has a deficiency in the leukocyte responsible for cell-mediated immunity. What should the nurse check the WBC count for?

T lymphocytes

A nurse practitioner reviewed the blood work of a male client suspected of having microcytic anemia. The nurse suspected occult bleeding. Which laboratory result would indicate an initial stage of iron deficiency? a.) Serum ferritin: 15 ng/mL b.) Total iron-binding capacity: 300 g/dL c.) Serum iron: 100 g/dL d.) Hemoglobin: 16 g/dL

a.) Serum ferritin: 15 ng/mL (Microcytic anemia is characterized by small RBCs due to insufficient hemoglobin. Serum ferritin levels correlate to iron deficiency and decrease as an initial response to anemia before hemoglobin and serum iron levels drop.)