exam 3 - blood transfusion IGGY

A nurse is preparing to administer a blood transfusion. What action is most important? a. Correctly identifying client using two identifiers b. Ensuring informed consent is obtained if required c. Hanging the blood product with Ringers lactate d. Staying with the client for the entire transfusion

ANS: B If the facility requires informed consent for transfusions, this action is most important because it precedes the other actions taken during the transfusion. Correctly identifying the client and blood product is a National Patient Safety Goal, and is the most important action after obtaining informed consent. Ringers lactate is not used to transfuse blood. The nurse does not need to stay with the client for the duration of the transfusion.

Which client is at greatest risk for having a hemolytic transfusion reaction? A. 34-year-old client with type O blood B. 42 year-old client with allergies C. 58 year-old immune suppressed client D. 78-year-old client

Correct answer A Hemolytic transfusion reactions are caused by blood type or Rh incompatibility. When blood that contains antigens different from the client's own antigens is infused, antigen-antibody complexes are formed in the client's blood. Type O is considered the universal donor but not the universal recipient.

A client who is receiving a blood transfusion suddenly exclaims to the nurse, "I don't feel right!" What does the nurse do next? A. Calls the Rapid Response Team. B. Obtains vital signs and continues to monitor. C. Slows the infusion rate of the transfusion. D. Stops the transfusion.

Correct answer D The client may be experiencing a transfusion reaction. The nurse should stop the transfusion immediately.

An 82-year-old client with anemia is requested to receive 2 units of whole blood. Which assessment finding causes the nurse to discontinue the transfusion because it is unsafe for the client? Select all that apply. A. Capillary refill less than 3 seconds B. Decreased pallor C. Flattened superficial veins D. Hypertension E. Hypotension F. Rapid, bounding pulse

Correct answers D,E,F D. Hypertension is a sign of overload in an older adult client who is receiving a transfusion. E. Low blood pressure is a sign of a transfusion reaction in an older adult who is receiving a blood transfusion. F. A rapid and bounding pulse is a sign of fluid overload in the older adult client who is being transfused. In this scenario, 2 units, or about a liter of fluid, could be problematic.

A nursing student asks the registered nurse why D5 W is contraindicated when transfusing blood. How does the nurse respond? a. "It causes hemolysis of blood cells." b. "It dilutes the cells." c. "It shrinks the blood cells." d. "It is in the procedure manual."

a

A patient is receiving a blood transfusion. Which solution does the nurse administer with the blood? a. Ringer's lactate b. Normal saline c. Dextrose in water d. Dextrose in saline .

b

To avoid transfusion reaction, the nurse is carefully monitoring the patient during a blood transfusion. When are hemolytic reactions to blood transfusion most likely to occur? a. 1 mL is sufficient b. 5 mL is typical c. Within the first 50 mL d. Occurs after 100 mL

c

A nurse is preparing to administer a blood transfusion to an older adult. Understanding age-related changes, what alterations in the usual protocol are necessary for the nurse to implement? (Select all that apply.) a. Assess vital signs more often. b. Hold other IV fluids running. c. Pre-medicate to prevent reactions. d. Transfuse smaller bags of blood. e. Transfuse each unit over 8 hours.

ANS: A, B The older adult needs vital signs monitored as often as every 15 minutes for the duration of the transfusion because changes may be the only indication of a transfusion-related problem. To prevent fluid overload, the nurse obtains a prescription to hold other running IV fluids during the transfusion. The other options are not warranted.

A student nurse is helping a registered nurse with a blood transfusion. Which actions by the student are most appropriate? (Select all that apply.) a. Hanging the blood product using normal saline and a filtered tubing set b. Taking a full set of vital signs prior to starting the blood transfusion c. Telling the client someone will remain at the bedside for the first 5 minutes d. Using gloves to start the clients IV if needed and to handle the blood product e. Verifying the clients identity, and checking blood compatibility and expiration time

ANS: A, B, D Correct actions prior to beginning a blood transfusion include hanging the product with saline and the correct filtered blood tubing, taking a full set of vital signs prior to starting, and using gloves. Someone stays with the client for the first 15 to 30 minutes of the transfusion. Two registered nurses must verify the clients identity and blood compatibility

A client receiving a blood transfusion develops anxiety and low back pain. After stopping the transfusion, what action by the nurse is most important? a. Documenting the events in the clients medical record b. Double-checking the client and blood product identification c. Placing the client on strict bedrest until the pain subsides d. Reviewing the clients medical record for known allergies

ANS: B This client had a hemolytic transfusion reaction, most commonly caused by blood type or Rh incompatibility. The nurse should double-check all identifying information for both the client and blood type. Documentation occurs after the client is stable. Bedrest may or may not be needed. Allergies to medications or environmental items is not related.

A postoperative patient receiving a transfusion of packed red blood cells develops chills, fever, headache, and anxiety 35 minutes after the transfusion is started. After stopping the transfusion, what action should the nurse take? a. Give the PRN diphenhydramine. b. Send a urine specimen to the laboratory. c. Administer PRN acetaminophen (Tylenol). d. Draw blood for a new type and crossmatch.

ANS: C The patient's clinical manifestations are consistent with a febrile, nonhemolytic transfusion reaction. The transfusion should be stopped and antipyretics administered for the fever as ordered. A urine specimen is needed if an acute hemolytic reaction is suspected. Diphenhydramine is used for allergic reactions. This type of reaction does not indicate incorrect crossmatching.

A patient in the emergency department complains of back pain and difficulty breathing 15 minutes after a transfusion of packed red blood cells is started. The nurse's first action should be to a. administer oxygen therapy at a high flow rate. b. obtain a urine specimen to send to the laboratory. c. notify the health care provider about the symptoms. d. disconnect the transfusion and infuse normal saline.

ANS: D The patient's symptoms indicate a possible acute hemolytic reaction caused by the transfusion. The first action should be to disconnect the transfusion and infuse normal saline. The other actions also are needed but are not the highest priority.

A nurse is preparing to hang a blood transfusion. Which action is most important? a. Documenting the transfusion b. Placing the client on NPO status c. Placing the client in isolation d. Putting on a pair of gloves

ANS: D To prevent bloodbourne illness, the nurse should don a pair of gloves prior to hanging the blood. Documentation is important but not the priority at this point. NPO status and isolation are not needed.

An RN assesses multiple clients who are receiving transfusions of blood components. Which assessment indicates the need for the RN's immediate action? A. A partial thromboplastin time (PTT) that is 1.2 times normal in a client who received a transfusion of fresh frozen plasma (FFP). B. Respiratory rate of 36 on a client receiving red blood cells (RBCs). C. Sleepiness in a client who received diphenhydramine (Benadryl) as a premedication. D. Temperature of 99.1° F (37.3° C) for a client with a platelet transfusion.

Correct answer B An increased respiratory rate indicates a possible hemolytic transfusion reaction. The nurse should quickly stop the transfusion and assess the client further.

A nurse is transfusing 2 units of packed red blood cells (PRBCs) to a postoperative client. What post-transfusion electrolyte imbalance does the nurse want to rule out? a. Hyponatremia b. Hyperkalemia c. Hypocalcemia d. High blood glucose

Correct answer B During transfusion, some cells are damaged. These cells release potassium, thus raising the client's serum potassium level (hyperkalemia). This complication is especially common with packed cells and whole blood products.

A nurse is transfusing a unit of whole blood to a client when the health care provider requests the following: "Furosemide (Lasix) 20 mg IV push." What does the nurse do? A. Adds Lasix to the normal saline that is infusing with the blood B. Administers Lasix to the client intramuscularly (IM) C. Piggy-backs Lasix into the infusing blood D. Waits until the transfusion has been completed to administer Lasix.

Correct answer D This is the best course of action in the scenario. The nurse should not administer Lasix while the blood is infusing. Stopping the infusing blood to administer the drug-and then re-starting it-is also not the best decision.

An older patient has been receiving frequent blood transfusions without any complications or adverse reactions; however, the nurse carefully monitors the patient during the current transfusion. Which signs/symptoms suggest that the patient is experiencing circulatory overload? a. Hypertension, bounding pulse, and distended neck veins b. Fever, chills, and tachycardia c. Urticaria, itching, and bronchospasm d. Headache, chest pain, and hemoglobinuria

a

The new registered nurse is giving a blood transfusion to a patient. Which statement by the new nurse indicates the need for action by the supervising nurse? a. "I will complete red blood cell transfusion within 6hours." b. "I will check the patient verification with another registered nurse." c. "I will use normal saline solution to dilute the blood." d. "I will remain with the patient for the first 15 to 30 minutes of the infusion."

a

25. The new registered nurse is identifying a patient for blood transfusion. Which action by the new nurse warrants intervention by the supervising nurse? a. Checks the health care provider's order before the blood transfusion b. Compares the identification name band and number to the blood component tag c. Cross-checks the patient's room number as a form of identification. d. Compares blood bag label and requisition slip to ensure compatibility of ABO and Rh

c

33. Which patient has the greatest risk for developing a febrile transfusion reaction? a. Patient is an older adult, and transfusion was given too rapidly b. Patient received an intraoperative autologous transfusion. c. Patient has received multiple blood transfusions for chronic bleeding. d. Patient sustained multiple injuries and needed an emergency transfusion.

c

51. A patient scheduled for surgery tells the nurse that he is fearful of the possibility of needing a blood transfusion. What is the nurse's best response? а. "Have you spoken with your health care provider about a family member donating blood for your transfusion?" b. "With today's technology, typing and receiving blood is a very safe procedure, and there is no need to worry. c. "Autologous transfusion, where you donate your own blood for later transfusion, may be an option for you." d. "Have you had previous unpleasant experiences with blood transfusions during past surgeries?"

c

The new registered nurse is identifying a patient for blood transfusion. Which action by the new nurse warrants intervention by the supervising nurse? a. Checks the health care provider's order before the blood transfusion b. Compares the hospital identification band name and number to those on the blood component tag c. Uses the patient's room number as a form of identification d. Examines blood bag tag and attached tag to ensure that the ABO and Rh types are compatible

c