Blood Admin / CVAD / Pain

A nurse receives a unit of packed RBCs from a blood bank and notes that the time is 1130. The nurse should begin the infusion at which of the following times?

As soon as the nurse can prepare the client and the administration set Rationale: The nurse should infuse the blood as soon as possible and complete the procedure within 4 hr.

A nurse is caring for a client who has expressive aphasia following a cerebrovascular accident (CVA). Which of the following parameters should the nurse use first in order to assess the client's pain level?

A self-report pain rating scale Rationale: Expressive aphasia results from damage to an area of the frontal lobe and is a motor speech problem. The client who has expressive aphasia is able to understand what is said but is unable to communicate verbally. However, this does not necessarily mean that a client is unable to reliably report pain. Evidence-based practice indicates the nurse should first attempt to obtain the client's self-report of pain. When assessing a client for pain, the nurse should utilize the hierarchy of pain measures which begins with self-report. It is always better to use a subjective method, such as a client report, instead of an objective method, such as something that is observable by the nurse, which is much less reliable.

Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress.

Potential Condition: - Transfusion-associated circulatory overload (TACO) Actions to Take: - Decrease the infusion rate - Administer furosemide Parameters to Monitor: - Monitor intake and output - Monitor weight Rationale: The nurse should decrease the rate of the transfusion and administer a furosemide or other diuretic as prescribed because the client is most likely experiencing transfusion-associated circulatory overload (TACO). The nurse should monitor the client's intake and output as well as the client's weight to assess fluid volume status, especially after the diuretic is administered.

Which of the following findings at 1015 requires further action? (Select all that apply.)

- Blood pressure - Low back pain - Urine color - Respiratory rate Rationale: - The client's blood pressure is less than the expected reference range. Hypotension is a manifestation of an acute transfusion reaction. The nurse should stop the transfusion and notify the provider. - Low back or flank pain is a manifestation of a transfusion reaction and requires interventions to reduce the risk for further injury. The nurse should stop the transfusion and notify the provider. - Reddish or dark brown urine is a manifestation of a transfusion reaction and requires interventions to reduce the risk for further injury. The nurse should stop the transfusion, notify the provider, and send a urine sample to the laboratory. - Tachypnea is a manifestation of a transfusion reaction and requires intervention to reduce the risk for further injury. The nurse should stop the transfusion and notify the provider. The client's WBC count is within the expected reference range.

A nurse is preparing to administer a transfusion of RBCs to a client who has heart failure. For which of the following manifestations should the nurse monitor to prevent fluid volume overload? (Select all that apply.)

- Dyspnea - Jugular vein distention - Confusion Rationale: - Dyspnea is a clinical manifestation of fluid volume overload. - Jugular vein distention is a clinical manifestation of fluid volume overload. - Confusion is a clinical manifestation of fluid volume overload.

A nurse is caring for a client who reports recurrent flank pain, nausea, and vomiting for 24 hr. Which of the following actions is the nurse's priority?

Administer pain medication Rationale: Using Maslow's hierarchy of needs, the nurse's priority is to meet the client's physiological need for comfort. Therefore, the first action the nurse should take is to administer pain medication to relieve the client's flank pain.

A nurse is monitoring a client who reports having chills and back pain during a blood transfusion. Which of the following actions is nurse's priority?

Stopping the transfusion Rationale: The greatest risk to this client is injury from a transfusion reaction, which is indicated by chills and back pain. Therefore, the priority intervention is to stop the infusion.

A nurse is caring for a client who has a prescription for one unit of packed RBCs. The nurse should plan to remain in the room with the client at which of the following times during the infusion to observe for a transfusion reaction?

The first 15 min Rationale: The nurse should remain in the room during the first 15 min of the infusion, which is the most critical time period for monitoring a client for a transfusion reaction. Severe reactions usually occur during the infusion of the first 50 mL of blood.

A nurse is planning to perform a blood transfusion for a client. Which of the following actions should the nurse plan to take? (Select all that apply.)

- Check vital signs before transfusion - Insert an IV with a 19-gauge needle - Check the expiration date of the blood product with a second nurse Rationale: - The nurse should check the client's vital signs immediately before starting the transfusion to create a baseline in order to assess a change in the vital signs during the transfusion. - The nurse should insert a large bore IV to transfuse the blood easily. - The expiration date, the client's name, the hospital number, and the blood compatibility are checked with two nurses to reduce the risk for a transfusion reaction.

A nurse is planning care for a client who is to receive packed RBCs. The nurse should plan for the total infusion time to not exceed which of the following?

4 hr Rationale: The nurse should infuse the packed RBCs for no longer than 4 hr due to temperature inconsistencies that develop over time and the possibility of bacterial contamination.

A nurse is caring for a client who had total hip arthroplasty 1 day ago and is receiving morphone sulfate by PCA pump for pain control. The client reports nausea and vomiting. Which of the following actions should the nurse take?

Auscultate bowel sounds Rationale: Using the nursing process, assessing for the presence or absence of bowel sounds and the passage of flatus is an appropriate action at this time. Determining the cause of the nausea and reducing contributing factors should precede any treatment.

A nurse is assessing a client who is receiving a platelet transfusion. Which of the following findings is an adverse effect of the transfusion?

Chills Rationale: Severe chills is an adverse effect of a platelet transfusion. The client might require premedication of diphenhydramine and acetaminophen to reduce this reaction.

A nurse remains with a client to observe for any adverse reactions after initiating a transfusion of packed RBCs. The client becomes apprehensive and tachycardic, reporting headache and low back pain. The nurse should recognize that these findings indicate which of the following transfusion reactions?

Hemolytic Rationale: In addition to tachycardia, headache, and low back pain, a hemolytic reaction can also cause fever, chills hypotension, possible chest pain, and hemoglobinuria.

A nurse is assessing a client who is receiving a blood transfusion. Which of the following findings is a manifestation of a hemolytic transfusion reaction?

Report of low-back pain Rationale: Low-back pain, fever, and chills are manifestations of a hemolytic transfusion reaction. The nurse should discontinue the transfusion and administer 0.9% sodium chloride through new IV tubing.

A nurse is caring for a client who is postoperative following abdominal surgery and reports incisional pain. The surgeon has prescribed morphine 4 mg IV bolus every 6 hr as needed. Before administering this medication, the nurse should complete which priority assessment?

Respiratory rate Rationale: The priority action the nurse should take when using the airway, breathing and circulation (ABC) approach to client care is to evaluate the client's respirations. The respiratory rate is especially important because opioid analgesics like morphine can cause respiratory depression.

A nurse is monitoring a client who is receiving packed RBCs. The nurse identifies which of the following as an expected finding?

The packed RBCs are connected by Y tubing to normal saline Rationale: The only intravenous fluid that can be used in the blood administration tubing is normal saline. It is used to prime the tube, and when the infusion is complete, it should also be used to clear the line. Y tubing allows for normal saline to infuse through one branch of the Y and packed RBCs through the other.

A nurse is providing information about pain control for a client who has acute pain following a subtotal gastric resection. Which of the following client statements indicates an understanding of pain control?

"I will call for pain medication before the previous dose wears off." Rationale: The client should call for pain medication before the previous dose of medication wears off or before the pain becomes severe.

A nurse is preparing to administer morphine 4 mg IV bolus to a client who reports pain. Available is morphine 10 mg/mL. Which of the following actions should the nurse take?

Have another nurse witness the disposal of the extra medication Rationale: Any excess narcotic must be disposed. The disposal must be witnessed and documented by a second nurse.

A nurse is preparing to administer a unit of red blood cells. The nurse's responsibility is to compare and verify the information on the blood label with the client's information. The nurse should use which of the following as the priority source of verification?

Identification wristband Rationale: This is the best option of the four to ensure that the nurse will deliver the correct unit of blood to the client to whom the provider prescribed it. Thus, this is the nurse's highest priority.

A nurse is assessing a client who reports acute pain. The nurse should anticipate which of the following findings?

Increased heart rate Rationale: Acute pain stimulates the sympathetic nervous system and can cause an increase in heart rate.

A nurse is administering morphine 2 mg IV every 2 to 4 hr to a client who has an abdominal incision. The nurse should monitor the client for which of the following adverse effects?

Orthostatic hypotension Rationale: The nurse should monitor the client for orthostatic hypotension and encourage the client to rise or change position slowly to decrease the risk for falls.

A nurse is completing discharge planning for a client who has bacterial endocarditis. The client will need to receive 12 weeks of antibiotic therapy. Which of the following venous access devices should the nurse identify as appropriate for the client?

Peripherally inserted central catheter Rationale: A peripherally inserted central catheter (PICC) line is the venous access device commonly used when the client needs extended, but not permanent, intravenous access. The PICC line may remain in place for weeks or months, PICC lines can also be used to draw blood samples without the need for additional venipunctures.

A nurse is reviewing the medication administration records of four clients who have a prescription for morphine PRN. Which of the following findings should the nurse identify as a contraindication to this medication?

The client has a paralytic ileus Rationale: Morphine is contraindicated in clients who have a paralytic ileus because morphine suppresses the propulsive contractions of the intestinal tract and inhibits secretion of fluids into the intestinal tract.

A nurse is caring for client who has a single lumen central venous catheter. Which of the following actions should the nurse take when accessing the catheter?

Use a 10-mL syringe to flush the catheter Rationale: During the flushing procedure, the nurse should use a 10-mL barrel syringe, because the pressure that is exerted by smaller barrel syringes increases the risk for rupturing the catheter.

A nurse is caring for a client who is using a patient-controlled analgesia (PCA) pump for postoperative pain management. The nurse enters the room to find the client asleep and his partner pressing the bottom to dispense another dose. Which of the following responses should the nurse make?

"Your husband should decide when more medication is needed." Rationale: The nurse should explain to the client's partner that the client is the only one who should operate the PCA pump. In situations where the client is not able to do so, the provider may authorize a nurse or a family member to operate the pump.

Which of the following actions should the nurse take? (Select all that apply.)

- Stop the client's blood transfusion - Request a prescription for an antipyretic medication - Begin infusing 0.9% sodium chloride solution Rationale: - The nurse should identify the client is experiencing a nonhemolytic febrile reaction to the donor blood and should stop the transfusion immediately. - The nurse should identify the client is experiencing a nonhemolytic febrile reaction to the donor blood, which is causing the client to experience fever. Therefore, the nurse should request a prescription for an antipyretic medication for the client. - The nurse should identify the client is experiencing a nonhemolytic febrile reaction to the donor blood. The nurse should stop the transfusion immediately and begin infusing 0.9% sodium chloride solution to keep the client's vein open.

A nurse is caring for a client is receiving hydromorphine HCL via PCA pump and reports continuous pain of 6 on a scale from 0 to 10. Which of the following actions should the nurse take first?

Check the display on the PCA pump Rationale: The first action the nurse should take using the nursing process is to assess the client; therefore, the nurse should assess the display on the PCA pump to determine the amount of medication administered. Some clients are fearful of developing an addiction to narcotics and may be reluctant to use the PCA.

A nurse is selecting a qualified staff member to double check a blood label with a client ID bracelet prior to infusing a unit of blood. The nurse should identify that which of the following persons is qualified?

Oncology nurse Rationale: The nurse should ask another nurse or a provider to double check the blood label and client ID prior to an infusion.

A nurse is caring for a client who is to start therapy with ibuprofen for hip pain. Which of the following information should the nurse provide about ibuprofen?

Take the medication with food Rationale: To minimize gastric irritation, the nurse should instruct the client to take ibuprofen with food, water, or milk.

A nurse is assessing a client before administering a unit of packed RBCs. The nurse should identify which of the following data as most important to obtain prior to the infusion?

Temperature Rationale: The greatest risk to the client is injury from a blood transfusion reaction. Therefore, the priority action is to take a baseline temperature measurement. The nurse should then monitor the client's temperature throughout the infusion as an increase in temperature can indicate an adverse reaction.