Exam 3 - Blood Transfusions

60. The client received two (2) units of packed red blood cells of 250 mL with 63 mL of preservative each during the shift. There was 240 mL of saline remaining in the 500-mL bag when the nurse discarded the blood tubing. How many milliliters of fluid should be documented on the intake and output record? _____________

*886 mL of fluid has infused.* 250 mL + 63 mL = 313 mL per unit 313 + 313 = 626 mL 500 mL of saline - 240 mL remaining = 260 mL infused. 626 mL + 260 mL = 886 mL of fluid infused. TEST-TAKING HINT: This problem has several steps but only requires basic addition and subtraction. The test taker should use the drop-down calculator on the computer to check or double-check the answer to make sure that simple mistakes are not made.

57. The client receiving a unit of PRBCs begins to chill and develops hives. Which action should be the nurse's first response? 1. Notify the laboratory and health-care provider. 2. Administer the histamine-1 blocker, Benadryl, IV. 3. Assess the client for further complications. 4. Stop the transfusion and change the tubing at the hub.

1. This should be done but after preventing any more of the PRBCs from infusing. 2. Benadryl may be administered to reduce the severity of the transfusion reaction, but it is not first priority. 3. The nurse should assess the client, but in this case the nurse has all the assessment data needed to stop the transfusion. *4. The priority in this situation is to prevent a further reaction if possible. Stopping the transfusion and changing the fluid out at the hub will prevent any more of the transfusion from entering the client's bloodstream.* TEST-TAKING HINT: In a question that requires the test taker to determine a priority action, the test taker must decide what will have the most impact on the client. Option "4" does this. All the options are interventions that should be taken, but only one will be first.

52. The client with O+ blood is in need of an emergency transfusion but the laboratory does not have any O+ blood available. Which potential unit of blood could be given to the client? 1. The O- unit. 2. The A+ unit. 3. The B+ unit. 4. Any Rh+ unit.

*1. O- (O-negative) blood is considered the universal donor because it does not contain the antigens A, B, or Rh. (AB+ is considered the universal recipient because a person with this blood type has all the antigens on the blood.)* 2. A+ blood contains the antigen A that the client will react to, causing the development of antibodies. The unit being Rh+ is compatible with the client. 3. B+ blood contains the antigen B that the client will react to, causing the development of antibodies. The unit being Rh+ is compatible with the client. 4. This client does not have antigens A or B on the blood. Administration of these types would cause an antigen-antibody reaction within the client's body, resulting in massive hemolysis of the client's blood and death. TEST-TAKING HINT: This is a knowledge-based question that requires memorization of the particular facts regarding blood typing. Three of the possible answer options have a positive (+) Rh factor; only one has a negative (-) Rh factor.

58. The nurse and an unlicensed assistive personnel (UAP) are caring for clients on an oncology floor. Which nursing task would be delegated to the UAP? 1. Assess the urine output on a client who has had a blood transfusion reaction. 2. Take the first 15 minutes of vital signs on a client receiving a unit of PRBCs. 3. Auscultate the lung sounds of a client prior to a transfusion. 4. Assist a client who received 10 units of platelets in brushing the teeth.

1. UAPs cannot assess. The nurse cannot delegate assessment. 2. The likelihood of a reaction is the greatest during the first 15 minutes of a transfusion. The nurse should never leave the client until after this time. The nurse should take and assess the vital signs during this time. 3. Auscultation of the lung sounds and administering blood based on this information are the nurse's responsibility. Any action requiring nursing judgment cannot be delegated. *4. The UAP can assist a client to brush the teeth. Instructions about using soft-bristle toothbrushes and the need to report to the nurse any pink or bleeding gums should be given prior to delegating the procedure.* TEST-TAKING HINT: The test taker must be aware of delegation guidelines. The nurse cannot delegate assessment or any intervention requiring nursing judgment. Options "1," "2," and "3" require judgment and cannot be delegated to a UAP.

54. The client undergoing knee replacement surgery has a "cell saver" apparatus attached to the knee when he arrives in the post-anesthesia care unit (PACU). Which intervention should the nurse implement to care for this drainage system? 1. Infuse the drainage into the client when a prescribed amount fills the chamber. 2. Attach an hourly drainage collection bag to the unit and discard the drainage. 3. Replace the unit with a continuous passive motion unit and start it on low. 4. Have another nurse verify the unit number prior to reinfusing the blood.

*1. A cell saver is a device to catch the blood lost during orthopedic surgeries to reinfuse into the client, rather than giving the client donor blood products. The cells are washed with saline and reinfused through a filter into the client. The salvaged cells cannot be stored and must be used within four (4) hours or discarded because of bacterial growth.* 2. The cell saver has a measuring device; an hourly drainage bag is part of a urinary drainage system. A cell saver is a sterile system that should not be broken until ready to disconnect for reinfusion. 3. The post-anesthesia care unit nurse would not replace the cell saver; it is inserted into the surgical wound. A continuous passive motion (CPM) machine can be attached on the outside of the bandage and started if the surgeon so orders, but this has nothing to do with the blood. 4. The blood has not been crossmatched so there is not a crossmatch number. TEST-TAKING HINT: The test taker could discard option "4" if the test taker realized that the laboratory is not involved with this blood at all. The test taker must have basic knowledge of surgical care.

49. The client has a hematocrit of 22.3% and a hemoglobin of 7.7 g/dL. The HCP has ordered two (2) units of packed red blood cells to be transfused. Which interventions should the nurse implement? *Select all that apply.* 1. Obtain a signed consent. 2. Initiate a 22-gauge IV. 3. Assess the client's lungs. 4. Check for allergies. 5. Hang a keep-open IV of D5W.

*1. The client must give permission to receive blood or blood products because of the nature of potential complications.* 2. Most blood products require at least a 20-gauge IV because of the size of the cells. RBCs are best infused through an 18-gauge IV. If unable to achieve cannulation with an 18-gauge, a 20-gauge is the smallest acceptable IV. Smaller IVs damage the cell walls of the RBCs and reduce the life expectancy of the RBCs. *3. Because infusing IV fluids can cause a fluid volume overload, the nurse must assess for congestive heart failure. Assessing the lungs includes auscultating for crackles and other signs of left-sided heart failure. Additional assessment findings of jugular vein distention, peripheral edema, and liver engorgement indicate right-sided failure.* *4. Checking for allergies is important prior to administering any medication. Some medications are administered prior to blood administration.* 5. A keep-open IV of 0.9% saline would be hung. D5W causes red blood cells to hemolyze in the tubing. TEST-TAKING HINT: This is an alternative-type question. This type of question can appear anywhere on the NCLEX-RN examination. Each answer option must be evaluated on its own merit. One will not rule out another. Assessing is the first step of the nursing process. Unless the test taker is absolutely sure that an option is wrong, the test taker could select an option based on "assessing," such as options "3" and "4." Ethically speaking, informed consent should always be given for any procedure unless an emergency life-or-death situation exists. The other options require knowledge of blood and blood product administration.

53. The client is scheduled to have a total hip replacement in two (2) months and has chosen to prepare for autologous transfusions. Which medication would the nurse administer to prepare the client? 1. Prednisone, a glucocorticoid. 2. Zithromax, an antibiotic. 3. Ativan, a tranquilizer. 4. Epogen, a biologic response modifier.

1. A steroid could delay healing time after the surgery and has no effect on the production of red blood cells. 2. An antibiotic does not increase the production of red blood cells. Orthopedic surgeries frequently involve blood loss. The client is wishing to donate blood to himself or herself (autologous). 3. Tranquilizers do not affect the production of red blood cells. *4. Epogen and Procrit are forms of erythropoietin, the substance in the body that stimulates the bone marrow to produce red blood cells. A client may be prescribed iron preparations to prevent depletion of iron stores and erythropoietin to increase RBC production. A unit of blood can be withdrawn once a week beginning at six (6) weeks prior to surgery. No phlebotomy will be done within 72 hours of surgery.* TEST-TAKING HINT: The test taker should examine the key words "autologous" and "transfusion." If the test taker did not know the meaning of the word "autologous," "auto-" as a prefix refers to "self," such as an autobiography is one's own story. Pairing "self" with "transfusion" then should make the test taker look for an option that would directly affect the production of blood cells.

55. Which statement is the scientific rationale for infusing a unit of blood in less than four (4) hours? 1. The blood will coagulate if left out of the refrigerator for >four (4) hours. 2. The blood has the potential for bacterial growth if allowed to infuse longer. 3. The blood components begin to break down after four (4) hours. 4. The blood will not be affected; this is a laboratory procedure.

1. Blood will coagulate if left out for an extended period, but blood is stored with a preservative that prevents this and prolongs the life of the blood. *2. Blood is a medium for bacterial growth, and any bacteria contaminating the unit will begin to grow if left outside of a controlled refrigerated temperature for longer than four (4) hours, placing the client at risk for septicemia.* 3. Blood components are stable and do not break down after four (4) hours. 4. These are standard nursing and laboratory procedures to prevent the complication of septicemia. TEST-TAKING HINT: The test taker must know the rationale behind nursing interventions to be able to answer this question.

51. The nurse is working in a blood bank facility procuring units of blood from donors. Which client would not be a candidate to donate blood? 1. The client who had wisdom teeth removed a week ago. 2. The nursing student who received a measles immunization two (2) months ago. 3. The mother with a six (6)-week-old newborn. 4. The client who developed an allergy to aspirin in childhood.

1. Oral surgeries are associated with transient bacteremia, and the client cannot donate for 72 hours after an oral surgery. 2. The client cannot donate blood for one (1) month following rubella immunization. *3. The client cannot donate blood for six (6) months after a pregnancy because of the nutritional demands on the mother.* 4. Recent allergic reactions prevent donation because passive transference of hypersensitivity can occur. This client has an allergy developed during childhood. TEST-TAKING HINT: All of the answer options have a given time period, and these time frames make each option correct or incorrect. The test taker must pay particular attention whenever an option contains time frames. Is it long enough or not frequent enough?

56. The HCP orders two (2) units of blood to be administered over eight (8) hours each for a client diagnosed with heart failure. Which intervention(s) should the nurse take? 1. Call the HCP to question the order because blood must infuse within four (4) hours. 2. Retrieve the blood from the laboratory and run each unit at an eight (8)-hour rate. 3. Notify the lab to split each unit into half-units and infuse each half for four (4) hours. 4. Infuse each unit for four (4) hours, the maximum rate for a unit of blood.

1. The HCP has written an appropriate order for this client, who has heart failure, and does not need to be called to verify the order before the nurse implements it. 2. Blood or blood components have a specified amount of infusion time, and this is not eight (8) hours. The time constraints are for the protection of the client. *3. The correct procedure for administering a unit of blood over eight (8) hours is to have the unit split into halves. Each half-unit is treated as a new unit and checked accordingly. This slower administration allows the compromised client, such as one with heart failure, to assimilate the extra fluid volume.* 4. This rate has all ready been determined by the HCP to be unsafe for this client. TEST-TAKING HINT: The key to this question is the time frame of eight (8) hours and the client's diagnosis of heart failure. Basic knowledge of heart failure allows the test taker to realize that fluid volume is the problem. Only one option addresses administering a smaller volume at a time.

59. The nurse is caring for clients on a medical floor. After the shift report, which client should be assessed first? 1. The client who is two thirds of the way through a blood transfusion and has had no complaints of dyspnea or hives. 2. The client diagnosed with leukemia who has a hematocrit of 18% and petechiae covering the body. 3. The client with peptic ulcer disease who called over the intercom to say that he is vomiting blood. 4. The client diagnosed with Crohn's disease who is complaining of perineal discomfort.

1. The likelihood of a client who has already received more than half of the blood product having a transfusion reaction is slim. The first 15 minutes have passed and to this point the client is tolerating the blood. 2. Clients diagnosed with leukemia have a cancer involving blood cell production. These are expected findings in a client diagnosed with leukemia. *3. This client has a potential for hemorrhage and is reporting blood in the vomitus. This client should be assessed first.* 4. Crohn's disease involves frequent diarrhea stools, leading to perineal irritation and skin excoriation. This is expected and not life threatening. Clients "1," "2," and "3" should be seen before this client. TEST-TAKING HINT: In a prioritizing question, the test taker should be able to rank in order which client to see first, second, third, and fourth. Expected but not immediately life-threatening situations are seen after a situation in which the client has a life-threatening problem.

The client is admitted to the emergency department after a motor-vehicle accident. The nurse notes profuse bleeding from a right-sided abdominal injury. Which intervention should the nurse implement first? 1. Type and crossmatch for red blood cells immediately (STAT). 2. Initiate an IV with an 18-gauge needle and hang normal saline. 3. Have the client sign a consent for an exploratory laparotomy. 4. Notify the significant other of the client's admission.

1. This should be done, but the client requires the IV first. This client is at risk for shock. *2. The first action in a situation in which the nurse suspects the client has a fluid volume loss is to replace the volume as quickly as possible.* 3. The client will probably need to have surgery to correct the source of the bleeding, but stabilizing the client with fluid resuscitation is first priority. 4. This is the last thing on this list in order of priority. TEST-TAKING HINT: The question requires the test taker to decide which of the actions comes first. Only one of the options actually has the nurse treating the client. The test taker must not read into a question—for example, that consent is needed to send a client to surgery to correct the problem, so that could be first. Only one answer option has the potential to stabilize the client.