Lloyd Bennett VSim

In a client experiencing blood loss during surgery, what direction would the nurse expect the postoperative hemoglobin level to change from the preoperative level? A) Decrease from preoperative level B) Stay within normal range C) Increase from preoperative level

A

The nurse must constantly monitor a client receiving a blood transfusion to ensure that there are no reactions or complications. Which of the following are signs and symptoms of a blood transfusion reaction? (Select all that apply.) A) Nausea B) Low back pain C) Fever, chills, or rigors D) Dyspnea E) Hypothermia

A, B, C, and D

In the first few minutes of the blood transfusion, Mr. Bennett says, 'I have back pain, and I don't feel well.' Upon further questioning, he states, 'I feel strange, and my chest hurts.' The nurse suspects that the Mr. Bennett is experiencing a possible transfusion reaction. What steps should the nurse take in a suspected transfusion reaction? (Select all that apply.) A) Notify the blood bank regarding the reaction. B) Send the blood container and tubing to the blood bank. C) Monitor blood pressure for hypertension. D) Maintain the IV line with D5W. E) Collect a urine sample. F) Document the reaction in the client record.

A, B, E, and F

The nurse recognizes that which of the following steps are essential to complete in the blood transfusion process for Mr. Bennett? (Select all that apply.) A) Check unit of blood for gas bubbles and cloudiness. B) Double-check the label with another registered nurse. C) Ensure administration time does not exceed 2 hours. D) Change the blood tubing with each unit. E) Instruct the client on signs and symptoms to report immediately. F) Assess vital signs.

A, B, E, and F

Which nursing action is appropriate before administering a unit of packed red blood cells? A) Use a blood warmer for all transfusions. B) Educate the client on the signs and symptoms of a blood reaction. C) Ensure a small-gauge IV is used to decrease discomfort. D) Vent the blood container to improve flow.

B

Which of the following are appropriate interventions to prevent deep vein thrombosis postoperatively in a client who has undergone hip arthroplasty? (Select all that apply.) A) Hip flexion (pillow under knee) B) Anti-embolism stockings C) Pneumatic compression device D) Ankle exercises E) Prophylactic anticoagulants

B, C, D, and E

Due to Mr. Bennett's age, there is a possibility of a transfusion-associated circulatory overload (TACO). Which of the following client clinical manifestations would represent this particular type of blood transfusion reaction? (Select all that apply.) A) Jugular vein distention B) Urticaria on the trunk C) Severe itching D) Crackles in the lungs E) Dyspnea F) Bronchospasm

A, D, and E

Lloyd Bennett is receiving a blood transfusion for operative blood loss. As part of the process of blood administration, the nurse needs to instruct Mr. Bennett on clinical manifestations to report related to acute hemolytic reaction. The nurse should include which of the following clinical manifestations that are possible in an acute hemolytic reaction? (Select all that apply.) A) Hypertension B) Dyspnea C) Itching D) Fever E) Chills F) Chest tightness

B, D, E, and F

The nurse completes all steps of the transfusion reaction protocol for Mr. Bennett. The nurse anticipates that which of the following clinical manifestations related to acute hemolytic transfusion reaction will appear if Mr. Bennett does not respond to medical treatment? (Select all that apply.) A) Hypertension B) Bronchospasm C) Increased urinary output D) Bilateral pulmonary infiltrates E) Anxiety F) Hemoglobinuria

B, E, and F

The provider has ordered a blood transfusion for the client. The blood transfusion was ordered based on the client's hemoglobin of 7 g/dL. The nurse is aware that the normal hemoglobin for a male client 76 years of age would be which of the following? A) 12-16 g/dL B) 35-47g/dL C) 13-18 g/dL D) 42-52g/dL

C

Which of the following does the nurse know is the most dangerous type of blood transfusion reaction? A) Delayed hemolytic B) Allergic C) Acute hemolytic D) Febrile non-hemolytic

C

The nurse recognizes that Mr. Bennett is most likely experiencing a blood transfusion reaction. The nurse's first critical step would be to ___(1)___, and then ___(2)___. Options for 1 A) Start another IV of normal saline B) Administer oxycodone as per providers orders C) Discontinue the blood transfusion D) Administer ondansetron as per providers orders Options for 2 A)Reassess vital signs in 30 minutes B) Notify the provider of client findings C) Flushes the IV tubing with normal saline D) Assess the client for hypervolemia

C and B

With a suspected blood transfusion reaction, what would the nurse's immediate priorities be? Place the tasks in the order in which the nurse should perform them, from highest priority to least priority. A) Check vital signs B) Notify the provider, but stay with the client C) Stop transfusion immediately D) Treat symptoms E) Notify the blood lab as per hospital policy F) Replace tubing containing blood with new tubing primed with NS; do not flush IV tubing containing blood; continue to maintain IV access G) Verify the client ID matches the blood label

C, F, A, B, G, D, and E