Brunner CH28 - Hematologic Function
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? 2:00 pm 3:00 pm 4:00 pm 6:00 pm
4:00 pm Explanation: When packed red blood cells (PRBCs) or whole blood is transfused, the blood should be administered within a 4-hour period because warm room temperatures promote bacterial growth.
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 Respiratory rate of 10 breaths/minute Oral temperature of 97°F Pain and tenderness in calf area
Crackles auscultated bilaterally Explanation: 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 decreased respiratory rate and decreased temperature are not manifestations of fluid overload. Pain and tenderness in the calf area may indicate a thrombosis which is not as common a manifestation as fluid overload.
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? Place the client in a recumbent position with legs elevated. Remove the intravenous line. Ensure there is an oxygen delivery device at the bedside. Administer prescribed PRN anti-anxiety agent.
Ensure there is an oxygen delivery device at the bedside. Explanation: The client is exhibiting signs of circulatory overload. After stopping the transfusion and notifying the healthcare provider, the nurse should place the client in a more upright position with the legs dependent to decrease workload on the heart. The IV line is kept patent in case emergency medications are needed. Oxygen and morphine may be needed to treat severe dyspnea. Administering an anti-anxiety agent is not a priority action over ensuring oxygen is available.
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-negative child Rh-positive mother; Rh-negative child Rh-negative mother; Rh-positive child Rh-positive mother; Rh-positive child
Rh-negative mother; Rh-positive child Explanation: A mother who is Rh negative and gives birth to an Rh positive child is at greatest risk for a febrile nonhemolytic reaction because exposure to an Rh-positive fetus raises antibody levels in the Rh negative mother. An Rh-negative mother can carry an Rh-negative child without being at greatest risk for a febrile nonhemolytic reaction; however, these mothers are often treated prophylactically. An Rh-positive mother may carry either an Rh-positive or Rh-negative child without increased risk.
A client who received 2 units of packed red blood cells 3 hours ago reports a new onset of dyspnea. Which additional assessment findings indicate to the nurse that the client is developing transfusion-related acute lung injury (TRALI)? Select all that apply. Jugular vein distention Temperature 102oF (38.8oC) Blood pressure 78/50 mm Hg Bilateral lower extremity edema Oxygen saturation 88% on room air
Temperature 102oF (38.8oC) Blood pressure 78/50 mm Hg Oxygen saturation 88% on room air Explanation: TRALI is a potentially fatal, idiosyncratic reaction that is defined as the development of acute lung injury occurring within 6 hours after the blood transfusion. Onset is abrupt (usually within 6 hours of transfusion, often within 2 hours). Signs and symptoms include acute shortness of breath, hypoxia, oxygen saturation less than 90%, hypotension and a fever. Jugular vein distention and bilateral lower extremity edema are associated with transfusion-associated circulatory overload.
One hour after the completion of a fresh frozen plasma transfusion, a client reports shortness of breath and is very anxious. The client's vital signs are BP 98/60, HR 110, temperature 99.4°F, and SaO2 88%. Auscultation of the lungs reveals posterior coarse crackles to the mid and lower lobes bilaterally. Based on the symptoms, the nurse suspects the client is experiencing which problem? Delayed hemolytic reaction Transfusion-related acute lung injury Exacerbation of congestive heart failure Bacterial contamination of blood
Transfusion-related acute lung injury Explanation: Transfusion-related acute lung injury (TRALI) is a potentially fatal, idiosyncratic reaction that is defined as the development of acute lung injury within 6 hours after a blood transfusion. It is more likely to occur when plasma and platelets are transfused. Onset is abrupt (usually within 6 hours of transfusion, often within 2 hours). Signs and symptoms include acute shortness of breath, hypoxia (arterial oxygen saturation [SaO2] less than 90%; pressure of arterial oxygen [PaO2] to fraction of inspired oxygen [FIO2] ratio less than 300), hypotension, fever, and eventual pulmonary edema.
A nurse is caring for a client who will undergo total knee replacement and will have an autologous transfusion. Which statement will the nurse include when teaching the client about the transfusion? "You typically donate blood the day of the surgery." "You will be prescribed calcium to replace what is lost during donation." "You typically donate blood 4 to 6 weeks before the surgery." "You will likely not need the blood that is donated."
"You typically donate blood 4 to 6 weeks before the surgery." Explanation: With autologous donation, a client's own blood may be collected for future transfusion; this is an effective method for orthopedic surgery, where the likelihood of transfusion is high. Preoperative donation is ideally collected 4-6 weeks before surgery. The nurse will not tell the client that the blood will not be needed; orthopedic surgeries often require transfusion of blood. The client will be prescribed iron supplements during the donation time, not calcium.
The physician orders a transfusion with packed red blood cells (RBCs) for a client hospitalized with severe iron deficiency anemia. When blood is administered, what is the most important action the nurse can take to prevent a transfusion reaction? Verify the client's identity according to hospital policy Administer the blood as soon as it arrives Premedicate the client with acetaminophen Assess the client 30 minutes after the start of the initial transfusion
Verify the client's identity according to hospital policy Explanation: Acute hemolytic transfusion reactions are preventable. Improper identification is responsible for the majority of hemolytic transfusion reactions. Meticulous attention to detail in labeling blood samples and blood components and accurately identifying the recipient cannot be overemphasized. It is the nurse's responsibility to ensure that the correct blood component is transfused to the correct client. The nurse must assess the client during the initial start of the transfusion and frequently, if the nurses delays the assessment time for 30 minutes the client may have begun to experience acute hemolytic transfusion reaction, this puts the client's safety at risk.
A preoperative client is discussing blood donation with the nurse. Which statement by the client indicates to the nurse the need for further teaching? "My family will donate blood, because it's safer." "I should expect blood withdrawal to take about 15 minutes." "Donated blood is tested for blood type and infections." "I could donate my own blood in case I need a transfusion."
"My family will donate blood, because it's safer." Explanation: Directed donations from friends and family members are not any safer than those provided by random donors. Withdrawal of 450 mL of blood usually takes about 15 minutes. Specimens from donated blood are tested to detect infections and to identify the specific blood type. Autologous blood donation is useful for many elective surgeries where the potential need for transfusion is high.
A client receiving a unit of packed red blood cells (PRBCs) has been prescribed morphine 1 mg intravenously now for pain. What is the best method for the nurse to administer the morphine? Add the morphine to the blood to be slowly administered. Inject the morphine into a distal port on the blood tubing. Administer the morphine into the closest tubing port to the client for fast delivery. Disconnect the blood tubing, flush with normal saline, and administer morphine.
Disconnect the blood tubing, flush with normal saline, and administer morphine. Explanation: Never add medications to blood or blood products. The transfusion must be temporarily stopped in order to administer the morphine.
A client is prescribed to receive 2 units of fresh frozen plasma (FFP). Place in order the steps the nurse will take to administer this blood product to the client. 1 Begin infusion 2 Obtain the FFP from the blood bank 3 Double-check the blood labels with another nurse 4 Ensure a 22-gauge catheter is in place 5 Flush the intravenous line with saline after the transfusion 6 Observe the client for signs of an adverse reaction 7 Monitor vital signs at the conclusion of the transfusion
Ensure a 22-gauge catheter is in place Obtain the FFP from the blood bank Double-check the blood labels with another nurse Begin infusion Observe the client for signs of an adverse reaction Monitor vital signs at the conclusion of the transfusion Flush the intravenous line with saline after the transfusion Explanation: When administering fresh frozen plasma, a 22-gauge or larger catheter should be in place before obtaining the FFP from the blood bank. The label on the FFP should be checked with another nurse before beginning the transfusion. Each unit of FFP should be infused between 30 and 60 minutes to prevent clumping of the platelets during the transfusion. The client should be closely observed during the transfusion for any signs of an adverse reaction. At the conclusion of the transfusion, the client's vital signs should be measured and compared with baseline measurements. The intravenous line should be flushed with saline afterwards to remove any blood components from the tubing.
A client is receiving platelets. In order to decrease the risk of circulatory overload in this client, what action should the nurse take? Administer each unit slowly over 3-4 hours. Infuse each unit over 30-60 minutes per client tolerance. Monitor vital signs closely before transfusion and once per shift. Flush the intravenous line with a liter of saline between units.
Infuse each unit over 30-60 minutes per client tolerance. Explanation: Infuse each unit of FFP over 30-60 minutes per client tolerance. Platelet clumping will occur if administered too slowly. Vital signs should be monitored before and throughout the transfusion, not just once per shift. A liter of saline is too large an amount to flush the intravenous line and would contribute to fluid overload.
A client scheduled for hip replacement surgery did not have enough time to have autologous donations completed. The nurse knows that which action will be performed if the client requires blood during the surgery? Hemodilution Plasmapheresis Direct donation Intraoperative blood salvage
Intraoperative blood salvage Explanation: Intraoperative blood salvage is a method for clients who are unable to donate blood before surgery and are having an orthopedic surgery. During the procedure, blood lost into a sterile cavity is suctioned into a cell-saver machine where is it is washed, filtered, and then infused into the client. Hemodilution is a transfusion method where 1 to 2 units of blood are removed after the induction of anesthesia and then reinfused after surgery. This approach has been linked to tissue ischemia of the kidneys. Plasmapheresis is the removal of plasma proteins and used for hyperviscosity syndromes and to treat some renal and neurologic diseases. It would not be applicable after joint replacement surgery. Direct donation is not routinely accepted by blood centers and would not be an action if the client requires blood during the surgery.
Place the following procedural steps in order for transfusing a unit of packed red blood cells (PRBCs). Double check the labels with another nurse to ensure correct ABO group and Rh type. Initiate the blood transfusion within 30 minutes of receipt. Start an intravenous line. Obtain the unit of PRBCs from the blood bank. Monitor closely for signs of a transfusion reaction.
Start an intravenous line. Obtain the unit of PRBCs from the blood bank. Double check the labels with another nurse to ensure correct ABO group and Rh type. Initiate the blood transfusion within 30 minutes of receipt. Monitor closely for signs of a transfusion reaction. Explanation: The nurse should first start an intravenous line, obtain the PRBCs, double check labels, start the transfusion, and then monitor for a reaction.
Place the following steps in order when determining the type and severity of a transfusion reaction. Use all options. 1 Notify the blood bank. 2 Send the tubing and container to the blood bank. 3 Stop the transfusion. 4 Assess the client. 5 Notify the health care provider.
Stop the transfusion. Assess the client. Notify the health care provider. Notify the blood bank. Send the tubing and container to the blood bank. Explanation: It is important for the nurse to take the proper steps when determining the type and severity of a transfusion reaction. The priority action is to stop the infusion and then assess the client. Next, the health care provider will be notified, followed by the blood bank. Finally, the nurse should send the tubing and container to the blood bank for analysis.
