Med-Surg: CH 32
Signs and symptoms of a transfusion reaction
Fresh-frozen plasma (FFP) has been ordered for a hospital patient. Prior to administration of this blood product, the nurse should prioritize what patient education?
Stop the transfusion immediately
The nurse caring for a patient receiving a transfusion notes that 15 minutes after the infusion of packed red blood cells (PRBCs) has begun, the patient is having difficulty breathing and complains of severe chest tightness. What is the most appropriate initial action for the nurse to take?
Increased production of erythropoietin
The nurse educating a patient with anemia is describing the process of RBC production. When the patient's kidneys sense a low level of oxygen in circulating blood, what physiologic response is initiated?
Liver and spleen
The nurse is caring for a patient who has developed scar tissue in many of the areas that normally produce blood cells. What organs can become active in blood cell production by the process of extramedullary hematopoiesis?
Hemoglobin
The nurse is describing normal RBC physiology to a patient who has a diagnosis of anemia. The nurse should explain that the RBCs consist primarily of which of the following?
All body fluids
The nurse is describing the role of plasminogen in the clotting cascade. Where in the body is plasminogen present?
Abnormalities in the structure and function RBCs
The nurse is planning the care of a patient with a nutritional deficit and a diagnosis of megaloblastic anemia. The nurse should recognize that this patient's health problem is due to what?
Administer the platelets as rapidly as the patient can tolerate
The nurse is preparing to administer a unit of platelets to an adult patient. When administering this blood product, which of the following actions should the nurse perform?
Older adults are less able to increase blood cell production when demand suddenly increases.
The nurse is providing care for an older adult who has a hematologic disorder. What age-related change in hematologic function should the nurse integrate into care planning?
The patient may chronically produce excess red blood cells.
The nurse's brief review of a patient's electronic health record indicates that the patient regularly undergoes therapeutic phlebotomy. Which of the following rationales for this procedure is most plausible?
Signs and symptoms of infection
The nurse's review of a patient's most recent blood work reveals a significant increase in the number of band cells. The nurse's subsequent assessment should focus on which of the following?
Leukocytes Platelets Erythrocytes
Through the process of hematopoiesis, stem cells differentiate into either myeloid or lymphoid stem cells. Into what do myeloid stem cells further differentiate? Select all that apply.
The chances of contracting AIDS from a blood transfusion in the United States are exceedingly low
Two units of PRBCs have been ordered for a patient who has experienced a GI bleed. The patient is highly reluctant to receive a transfusion, stating, I'm terrified of getting AIDS from a blood transfusion. How can the nurse best address the patient's concerns?
The patient has elective surgery pending.
Which of the following circumstances would most clearly warrant autologous blood donation?
Anemia
A client's health history reveals daily consumption of two to three bottles of wine. The nurse should plan assessments and interventions in light of the patient's increased risk for what hematologic disorder?
Severed blood vessels constrict.
A man suffers a leg wound which causes minor blood loss. As a result of bleeding, the process of primary hemostasis is activated. What occurs in primary hemostasis?
Help her into a sitting position with her head lowered below her knees.
A nurse at a blood donation clinic has completed the collection of blood from a woman. The woman states that she feels lightheaded and she appears visibly pale. What is the nurse's most appropriate action?
A woman whose blood pressure is 88/51 mm Hg
A nurse has participated in organizing a blood donation drive at a local community center. Which of the following individuals would most likely be disallowed from donating blood?
Severe fatigue
A nurse is caring for a patient who undergoing preliminary testing for a hematologic disorder. What sign or symptom most likely suggests a potential hematologic disorder?
Antibody production
A nurse is educating a patient about the role of B lymphocytes. The nurse's description will include which of the following physiologic processes?
Plasma cells
A patient has been diagnosed with a lymphoid stem cell defect. This patient has the potential for a problem involving which of the following?
Most people feel some brief, sharp pain when the needle enters the bone.
A patient has been scheduled for a bone marrow biopsy and admits to the nurse that she is worried about the pain involved with the procedure. What patient education is most accurate?
Iron
A patient has come to the OB/GYN clinic due to recent heavy menstrual flow. Because of the patient's consequent increase in RBC production, the nurse knows that the patient may need to increase her daily intake of what substance?
The patient is a vegan.
A patient is being treated for the effects of a longstanding vitamin B12 deficiency. What aspect of the patient's health history would most likely predispose her to this deficiency?
The donor blood was incompatible with that of the patient.
A patient is being treated in the ICU after a medical error resulted in an acute hemolytic transfusion reaction. What was the etiology of this patient's adverse reaction?
Slow the infusion rate and monitor the patient closely.
A patient is receiving a blood transfusion and complains of a new onset of slight dyspnea. The nurse's rapid assessment reveals bilateral lung crackles and elevated BP. What is the nurse's most appropriate action?
Discontinue the transfusion.
A patient is receiving the first of two ordered units of PRBCs. Shortly after the initiation of the transfusion, the patient complains of chills and experiences a sharp increase in temperature. What is the nurse's priority action?
The need to report any signs or symptoms of infection promptly
A patient is scheduled for a splenectomy. During discharge education, what teaching point should the nurse prioritize?
Iron overload
A patient lives with a diagnosis of sickle cell anemia and receives frequent blood transfusions. The nurse should recognize the patient's consequent risk of what complication of treatment?
Discontinue the remainder of the PRBC transfusion and inform the physician.
A patient on the medical unit is receiving a unit of PRBCs. Difficult IV access has necessitated a slow infusion rate and the nurse notes that the infusion began 4 hours ago. What is the nurse's most appropriate action?
Prevention of viral infections from another person's blood
A patient undergoing a hip replacement has autologous blood on standby if a transfusion is needed. What is the primary advantage of autologous transfusions?
In the bone marrow
A patient with a hematologic disorder asks the nurse how the body forms blood cells. The nurse should describe a process that takes place where?
Review the patient's international normalized ratio (INR).
A patient's diagnosis of atrial fibrillation has prompted the primary care provider to prescribe warfarin (Coumadin), an anticoagulant. When assessing the therapeutic response to this medication, what is the nurse's most appropriate action?
Hemophilia
A patient's electronic health record states that the patient receives regular transfusions of factor IX. The nurse would be justified in suspecting that this patient has what diagnosis?
Assess the patient's vital signs to establish baselines.
A patient's low hemoglobin level has necessitated transfusion of PRBCs. Prior to administration, what action should the nurse perform?
Risk for imbalanced fluid volume related to low albumin
A patient's most recent blood work reveals low levels of albumin. This assessment finding should suggest the possibility of what nursing diagnosis?
Plasmin
A patient's wound has begun to heal and the blood clot which formed is no longer necessary. When a blood clot is no longer needed, the fibrinogen and fibrin will be digested by which of the following?
Platelets will aggregate at the injury site.
An individual has accidentally cut his hand, immediately initiating the process of hemostasis. Following vasoconstriction, what event in the process of hemostasis will take place?
Be vigilant in identifying the patient and the blood component.
An interdisciplinary team has been commissioned to create policies and procedures aimed at preventing acute hemolytic transfusion reactions. What action has the greatest potential to reduce the risk of this transfusion reaction?
Stool for occult blood
An older adult client is exhibiting many of the characteristic signs and symptoms of iron deficiency. In addition to a complete blood count, what diagnostic assessment should the nurse anticipate?
