Blood review Q's

A nurse is preparing to initiate a transfusion of packed RBC for a client who has anemia. Which of the following actions should the plan to nurse take? A. Leave the client 5 min after beginning the transfusion. B. Infuse the transfusion at a rate of 200 mL/hr. C. Check the client's vital signs every hour during the transfusion. D. Flush the blood tubing with dextrose 5% in water.

. A nurse is preparing to initiate a transfusion of packed RBC for a client who has anemia. Which of the following actions should the plan to nurse take? A. Leave the client 5 min after beginning the transfusion. Rationale: The nurse should remain with the client for 15 to 30 min after the start of the transfusion to monitor for a reaction, which usually occurs during the first 50 mL of the transfusion. B. Infuse the transfusion at a rate of 200 mL/hr.Rationale: The transfusion should infuse in 2 to 4 hr to prevent fluid overload. C. Check the client's vital signs every hour during the transfusion. Rationale: The nurse should check the client's vital signs every 15 min at the start of the transfusion, then every 1 hr to monitor for a transfusion reaction. D. Flush the blood tubing with dextrose 5% in water. Rationale: The nurse should flush the blood tubing with 0.9% sodium chloride to prevent hemolysis of the blood.

Dana just received a blood transfusion at 1300. At what time should Dana's blood transfusion be finished?

1700. Blood transfusions should only be running for a maximum of 4 hours because of the risk of bacterial growth.

A nurse is assessing a client who is receiving a unit of packed RBCs. The client appears flushed and reports low-back pain. Which of the following actions is the nurse's priority? A. Stop the transfusion. B. Collect a urine specimen. C. Notify the blood bank. D. Begin an infusion of 0.9% sodium chloride through new tubing.

A nurse is assessing a client who is receiving a unit of packed RBCs. The client appears flushed and reports low-back pain. Which of the following actions is the nurse's priority? A. Stop the transfusion. Rationale: The greatest risk to the client is injury due to further hemolysis; therefore, the priority action is to stop the transfusion. When a hemolytic reaction is suspected, the priority action by the nurse is to immediately stop the transfusion to prevent further hemolysis. B. Collect a urine specimen. Rationale: The client is at risk for hemoglobinuria and acute kidney injury due to hemolysis, so a urine specimen is required; however, another action is the priority. C. Notify the blood bank. Rationale: The client is at risk for hypotension and shock due to hemolysis, and the nurse must notify the blood bank to determine the cause of the hemolytic reaction; however, another action is the priority. D. Begin an infusion of 0.9% sodium chloride through new tubing. Rationale: The client is at risk for hypotension and shock due to hemolysis, so it is important to keep an IV open to administer fluids and medications; however, another action is the priority

A nurse is assessing a client who is receiving a unit of packed red blood cells. Which of the following findings is a manifestation of acute hemolytic reaction? A. Client report of low back pain B. Client report of tinnitus C. A productive cough D. Distended neck veins

A nurse is assessing a client who is receiving a unit of packed red blood cells. Which of the following findings is a manifestation of acute hemolytic reaction? A. Client report of low back pain Rationale: Manifestations of an acute hemolytic reaction include apprehension, tachypnea, hypotension, chest pain, and lower back pain. B. Client report of tinnitusRationale: Tinnitus is a manifestation of ototoxicity and is an adverse effect of aminoglycoside antibiotics. C. A productive coughRationale: A cough is a manifestation of circulatory overload. D. Distended neck veinsRationale: Distended neck veins are a manifestation of circulatory overload.

A nurse is caring for a client who is receiving a blood transfusion. Which of the following actions should the nurse expect if an allergic transfusion reaction is suspected? (Select all that apply.) A. Stop the transfusion. B. Monitor for hypertension. C. Maintain an IV infusion with 0.9% sodium chloride. D. Position the client in an upright position with the feet lower than the heart. E. Administer diphenhydramine.

A nurse is caring for a client who is receiving a blood transfusion. Which of the following actions should the nurse expect if an allergic transfusion reaction is suspected? (Select all that apply.) A. Stop the transfusion. B. Monitor for hypertension. C. Maintain an IV infusion with 0.9% sodium chloride. D. Position the client in an upright position with the feet lower than the heart. E. Administer diphenhydramine. The nurse should immediately stop the infusion if an allergic transfusion reaction is suspected.The nurse should administer 0.9%sodium chloride solution through new IV tubingThe nurse should administer an antihistamine, such asdiphenhydramine, if an allergic transfusion reaction is suspected.

A nurse is caring for a client who is receiving a unit of packed red blood cells. Fifteen minutes following the start of the transfusion, the nurse notes that the client is febrile, with chills and red-tinged urine. Which of the following transfusion reactions should the nurse suspect? A. Allergic B. Febrile C. Hemolytic D. Acute pain

A nurse is caring for a client who is receiving a unit of packed red blood cells. Fifteen minutes following the start of the transfusion, the nurse notes that the client is febrile, with chills and red-tinged urine. Which of the following transfusion reactions should the nurse suspect? A. Allergic B. Febrile C. Hemolytic D. Acute pain

A nurse is caring for a client who is to receive a unit of packed RBCs. The nurse should prime the blood administration tubing using which of the following IV solutions? A. Lactated Ringer's solution B. 0.9% sodium chloride C. Dextrose 5% in water D. Dextrose 5% in 0.45% sodium chloride

A nurse is caring for a client who is to receive a unit of packed RBCs. The nurse should prime the blood administration tubing using which of the following IV solutions? A. Lactated Ringer's solution Rationale: The nurse should not prime the tubing with lactated Ringer's solution, because it hemolyzes RBCs. B. 0.9% sodium chloride Rationale: The nurse should prime the tubing with 0.9% sodium chloride, as this is the only IV solution that does not hemolyze RBCs. C. Dextrose 5% in water Rationale: The nurse should not prime the tubing with dextrose 5% in water, because it hemolyzes RBCs. D. Dextrose 5% in 0.45% sodium chloride Rationale: The nurse should not prime the tubing with dextrose 5% in water, because it hemolyzes RBCs.

A nurse is monitoring a client who began receiving a unit of packed RBCs 10 min ago. Which of the following findings should the nurse identify as an indication of a febrile transfusion reaction? (Select all that apply.) A. Temperature change from 37° C (98.6° F) pre-transfusion to 37.2° C (99.0° F) B. Current blood pressure 178/90 mm Hg C. Heart rate change from 88/min pre-transfusion to 120/min D. Client report of itching E. Client appears flushed

A nurse is monitoring a client who began receiving a unit of packed RBCs 10 min ago. Which of the following findings should the nurse identify as an indication of a febrile transfusion reaction? (Select all that apply.) A. Temperature change from 37° C (98.6° F) pre-transfusion to 37.2° C (99.0° F) B. Current blood pressure 178/90 mm Hg C. Heart rate change from 88/min pre-transfusion to 120/min D. Client report of itching E. Client appears flushed Tachycardia is an indication of a febrile transfusion reactionA flushed appearance of the client can indicate a febrile transfusion reaction.

A nurse is monitoring a client who is receiving a unit of packed RBCs following surgery. Which of the following assessments is an indication that the client might be experiencing circulatory overload? A. Flushing B. Dyspnea C. Bradycardia D. Vomiting

A nurse is monitoring a client who is receiving a unit of packed RBCs following surgery. Which of the following assessments is an indication that the client might be experiencing circulatory overload? A. Flushing Rationale: Flushing is a sign of an allergic reaction to a blood transfusion, not of circulatory overload. B. Dyspnea Rationale: Circulatory overload causes dyspnea, cough, rales, tachycardia, and jugular vein distention. C. Bradycardia Rationale: Circulatory overload causes tachycardia, not bradycardia. D. Vomiting Rationale: Vomiting is a sign of a septic reaction to a blood transfusion, not of circulatory overload.

A nurse is monitoring a client who is receiving a unit of packed RBCs following surgery. Which of the following assessments is an indication the client might be experiencing a hemolytic reaction? A. Flushing B. Dyspnea C. Hypotension D. Vomiting

A nurse is monitoring a client who is receiving a unit of packed RBCs following surgery. Which of the following assessments is an indication the client might be experiencing a hemolytic reaction? A. Flushing Rationale: Flushing is a sign of an allergic reaction to a blood transfusion, not of a hemolytic reaction. B. Dyspnea Rationale: Dyspnea is a sign of circulatory overload from a blood transfusion, not of a hemolytic reaction. C. Hypotension Rationale: A hemolytic reaction causes hypotension, headache, apprehension, chest pain, and low-back pain. D. Vomiting Rationale: Vomiting is a sign of a septic reaction to a blood transfusion, not of a hemolytic reaction.

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.) A. Dyspnea B. Gastrointestinal bloating C. Jugular vein distention D. Confusion E. Hypotension

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.) A. Dyspnea B. Gastrointestinal bloating C. Jugular vein distention D. Confusion E. Hypotension Rationale: Dyspnea is correct. Dyspnea is a clinical manifestation of fluid volume overload. Gastrointestinal bloating is incorrect. Gastrointestinal bloating is not a clinical manifestation of heart failure. Jugular vein distention is correct. Jugular vein distention is a clinical manifestation of fluid volume overload. Confusion is correct. Confusion is a clinical manifestation of fluid volume overload. Hypotension is incorrect. Hypertension, not hypotension, is a clinical manifestation of fluid volume overload. Hypotension is a manifestation of a hemolytic transfusion reaction.

A nurse is preparing to administer packed RBCs to a client who has a Hgb of 8 g/dL. Which of the following actions should the nurse plan to take during the first 15 min of the transfusion? A. Obtain consent from the client for the transfusion. B. Assess for an acute hemolytic reaction. C. Explain the transfusion procedure to the client. D. Obtain blood culture specimens to send to the lab.

A nurse is preparing to administer packed RBCs to a client who has a Hgb of 8 g/dL. Which of the following actions should the nurse plan to take during the first 15 min of the transfusion? A. Obtain consent from the client for the transfusion. B. Assess for an acute hemolytic reaction. C. Explain the transfusion procedure to the client. D. Obtain blood culture specimens to send to the lab The nurse should assess for an acute hemolytic reactionduring the first 15 min of the transfusion. This form of a reaction can occur following the transfusion of as little as 10 mL of blood product.

A nurse is preparing to transfuse one unit of packed RBC to a client who experienced a mild allergic reaction during a previous transfusion. The nurse should administer diphenhydramine prior to the transfusion for which of the following allergic responses? A. Urticaria B. Fever C. Fluid overload D. Hemolysis

A nurse is preparing to transfuse one unit of packed RBC to a client who experienced a mild allergic reaction during a previous transfusion. The nurse should administer diphenhydramine prior to the transfusion for which of the following allergic responses? A. Urticaria Rationale: For clients who have previously had allergic reactions to blood transfusions, administering an antihistamine such as diphenhydramine prior to the transfusion might prevent future reactions. Allergic reactions typically include urticaria (hives). B. Fever Rationale: An antihistamine will not prevent a febrile, non-hemolytic reaction to a blood transfusion. A possible preventive measure is transfusing leucocyte-poor blood products to avoid sensitization to the donor's WBC. C. Fluid overload Rationale: An antihistamine will not prevent fluid overload. Transfusing the blood product slowly and not exceeding the volume that is necessary can reduce this risk. D. Hemolysis

A nurse is providing preoperative teaching for a client who requests autologous donation in preparation for a scheduled orthopedic surgical procedure. Which of the following statements should the nurse include in the teaching? A. "You should make an appointment to donate blood 8 weeks prior to the surgery." B. "If you need an autologous transfusion, the blood your brother donates can be used." C. "You can donate blood each week if your hemoglobin is stable." D. "Any unused blood that is donated can be used for other clients."

A nurse is providing preoperative teaching for a client who requests autologous donation in preparation for a scheduled orthopedic surgical procedure. Which of the following statements should the nurse include in the teaching? A. "You should make an appointment to donate blood 8 weeks prior to the surgery." B. "If you need an autologous transfusion, the blood your brother donates can be used." C. "You can donate blood each week if your hemoglobin is stable." D. "Any unused blood that is donated can be used for other clients." Beginning 6 weeks prior to surgery, the client can donate blood each week for autologous transfusion if his Hgb and Hct remain stable.

A nurse is preparing to administer a unit of packed red blood cells to a client. Which of the following actions should the nurse plan to take? A. Check the unit of blood with an assistant personal (AP). B. Premedicate the client with an antiemetic. C. Plan to infuse the unit of blood over 6 hr. D. Remain with the client for the first 15 minutes of the transfusion.

A. Check the unit of blood with an assistant personal (AP). Rationale: Two RNs or an RN and a practical nurse (PN) (in certain institutions) can check a unit of blood before it is transfused. This action is outside the scope of practice for an AP. B. Premedicate the client with an antiemetic. Rationale: The client might require premedication with an antipyretic, but not an antiemetic. C. Plan to infuse the unit of blood over 6 hr. Rationale: The unit of blood should infuse within 4 hr to reduce the risk for bacteria growth. D. Remain with the client for the first 15 minutes of the transfusion. Rationale: The nurse should remain with the client for the first 15 to 30 minutes of the transfusion to monitor for a transfusion reaction, which occurs often during the first 50 mL of the transfusion

A nurse is caring for a client who is receiving a transfusion of packed red blood cells and suspects that the client is experiencing a hemolytic reaction. Which of the following interventions is the priority? A. Collect a urine specimen. B. Administer 0.9% sodium chloride through the IV line. C. Stop the transfusion. D. Notify the blood bank.

A. Collect a urine specimen. Rationale: The client is at risk for hemoglobinuria and acute kidney injury due to hemolysis; however, another action is the priority. B. Administer 0.9% sodium chloride through the IV line. Rationale: The client is at risk for hypotension and shock due to hemolysis, so it is important to keep an IV open to administer fluids and medications; however, another action is the priority. C. Stop the transfusion. Rationale: The greatest risk to the client is injury due to further hemolysis; therefore, the priority action is to stop the transfusion. When suspecting a hemolytic reaction, the priority action by the nurse is to immediately stop the transfusion to prevent further hemolysis. D. Notify the blood bank. Rationale: The client is at risk for hypotension and shock due to hemolysis, and the nurse must notify the blood bank to determine the cause of the hemolytic reaction; however, another action is the priority.

A charge nurse is supervising a newly licensed nurse care for a client who is receiving a transfusion of packed RBC. The nurse suspects a possible hemolytic reaction. After stopping the blood transfusion, which of the following actions by the new nurse requires intervention by the charge nurse? A. The nurse initiates an infusion of 0.9% sodium chloride. B. The nurse collects a urine specimen. C. The nurse sends a blood specimen to the laboratory. D. The nurse starts the transfusion of another unit of blood product.

A. The nurse initiates an infusion of 0.9% sodium chloride. Rationale: When suspecting a hemolytic reaction, the nurse should maintain IV access and blood volume with an infusion of 0.9% sodium chloride. B. The nurse collects a urine specimen. Rationale: When suspecting a hemolytic reaction, the nurse should obtain a urine specimen to assess for the presence of hemoglobin in the urine. C. The nurse sends a blood specimen to the laboratory. Rationale: When suspecting a hemolytic reaction, the nurse should obtain a blood specimen from the client for laboratory analysis. D. The nurse starts the transfusion of another unit of blood product. Rationale: When suspecting a hemolytic reaction, the nurse should immediately stop the transfusion of all blood products. The transfusion of additional products can increase the client's risk for further complication.

A nurse is preparing to administer blood to a client. The unit of blood on hand is type negative, and the client has type A positive blood. Which of the following actions should the nurse take?

Administer the blood is ordered. The nurse should administer the blood as ordered. Type O blood is compatible with Type A. Type O blood is considered a universal donor as it contains no antigens to react to transfused blood.

A patient experiencing a blood transfusion reaction is prescribed to receive epinephrine. What is the purpose of this medication when given for this indication? a. To relieve respiratory distress b. To block histamine receptors c. To reduce circulatory overload d. To combat bacterial infection

a. To relieve respiratory distress

A nurse preceptor is observing a newly licensed nurse on the unit who is preparing to administer a blood transfusion to an older adult client. Which of the following actions by the newly licensed nurse indicates an understanding of the procedure? A. Inserts an 18‐gauge IV catheter in the client B. Verifies blood compatibility and expiration date of the blood with an assistive personnel (AP) C. Administers dextrose 5% in 0.9% sodium chloride IV with the transfusion D. Obtains vital signs every 15 min throughout the procedure.

D. Obtains vital signs every 15 min throughout the procedure. The nurse should check the older adult client'svital signs every 15 min throughout the transfusion to allow for early detection of fluid overload or other transfusion 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

Jane has just received a blood transfusion of packed red blood cells. It has been 15 minutes since the initiation of the blood transfusion, and Jane is now experiencing chills, nausea, chest tightness, and anxiety. You check her vitals and notice that her pulse rate is 110 and her blood pressure is 90/50. Which type of adverse reaction is Jane experiencing?

Jane is experiencing an acute hemolytic reaction.

A patient is experiencing circulatory overload following a blood transfusion. What nursing actions should be performed to treat this adverse reaction?

STOP the transfusion. Place the patient upright with the feet lower than the heart. Administer oxygen, diuretics, and morphine as needed.

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

If a patient is experiencing circulatory overload while receiving a blood transfusion, what is the likely cause of this?

The blood transfusion is transfusing too rapidly.

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 minutes.

Leo was started on a blood transfusion at 1500. It is now 1700 and he is experiencing chills, hypotension, and tachycardia. After stopping the blood transfusion, the nurse would perform what actions next?

The nurse would administer an antipyretic and initiate NaCl.

Travis has been receiving a blood transfusion for the past 3 hours and is now experiencing wheezing, dyspnea, chest tightness, and cyanosis. What is the most likely cause for his symptomatology?

Travis is experiencing a bacterial blood transfusion reaction, indicating that the blood product must have been contaminated.

While checking a blood bag prior to infusion, the nurse notes that the patient's blood type is A+ and the donor's blood type is O+. Which action would the nurse take? a. Administer the blood. b. Return the blood to the blood bank. c. Notify the physician. d. Ask the patient if anyone in the family has blood type A+.

a. Administer the blood.A patient whose blood type is A+ can receive blood from a donor whose blood type is O+.

It is determined that a patient who received a blood transfusion received an infection from the blood. Whom should the nurse notify of this infection? a. Blood bank and infection control department b. State health department c. U.S. Centers for Disease Control and Prevention d. Centers for Medicare and Medicaid or the patient's private insurer

a. Blood bank and infection control department The nurse should report sepsis and other transfusion-related infections to the blood bank and to the agency's infection control department.

A patient has a blood transfusion reaction, and the transfusion is stopped. What should the nurse do with the remaining blood and transfusion administration set? a. Return both to the blood bank. b. Return the blood to the blood bank, and discard the tubing. c. Discard both the blood and tubing. d. Send the blood and the tubing to the laboratory for analysis.

a. Return both to the blood bank. After a transfusion reaction, the remainder of the blood component and the attached tubing must be returned to the blood bank according to agency policy.

While checking a blood product prior to administration, the nurse is called away to assist with another procedure. What should the nurse do with the blood product? a. Return it to the blood bank until it can be administered. b. Ask another nurse to administer it to the patient. c. Ask nursing assistive personnel (NAP) to place it in the unit refrigerator if you expect to be gone less than 30 minutes. d. Leave it in the patient's room.

a. Return it to the blood bank until it can be administered. An infusion of blood or blood products must be initiated within 30 minutes of obtaining the unit from the blood bank. If the infusion cannot be initiated within that period, the blood must be returned to the blood bank until the infusion can be initiated.

The nurse is preparing equipment to administer a unit of blood to a patient. Which type of fluid would the nurse piggyback with the blood transfusion? a. 0.45% normal saline b. 0.9% normal saline c. Dextrose 5% and 0.45% normal saline d. Dextrose 5% and 0.9% normal saline

b. 0.9% normal saline

A patient is to receive one unit of packed red blood cells over 2 hours. Which rate is the usual flow rate for the first 15 minutes of a blood transfusion? a. 1 mL/min b. 2 mL/min c. 10 mL/min d. 25 mL/min

b. 2 mL/min * PP said 1-2 mL/ min so idkkkk

An adult patient is prescribed to receive a unit of packed red blood cells. Which size intravenous catheter does the patient need to safely receive this blood? a. 30-gauge b. 25-gauge c. 18-gauge d. 10-gauge

c. 18-gaugeBlood should be administered to an adult using a 14- to 20-gauge short peripheral catheter.

The nurse is preparing to administer a unit of blood to a patient in the emergency department and discovers that he is not wearing an identification bracelet. What should the nurse do? a. Identify the patient by asking him to produce a photo ID, such as a driver's license. b. Administer the blood only if you have been caring for the patient and can be certain of his identity. c. Return the unit to the blood bank. d. Identify the patient by asking a family member to identify him.

c. Return the unit to the blood bank.

Fifteen minutes following blood administration, your patient develops dyspnea, a cough, and a rapid heart rate. You suspect a. Sepsis b. Anaphylaxis c. Acute hemolytic reaction d. Circulatory overload

d. Circulatory overload

While checking a blood product prior to administration, the nurse notices that the birth date on the blood bag and requisition do not match the birth date on the patient's identification bracelet. Which is the correct action for the nurse to take? a. Be especially vigilant for adverse reactions during the infusion. b. Ask the patient to state his or her birth date c. Correct the birth date on the blood bag and requisition. d. Return the blood to the blood bank.

d. Return the blood to the blood bank. If there is any discrepancy in the patient's birth date or other identifying information, the product must not be administered. Notify the blood bank and other appropriate personnel, as indicated by your agency's policy. Return the blood to the blood bank until the discrepancy has been resolved.

A patient prescribed to receive two units of packed red blood cells is to receive a dose of intravenous medication between the two units. How would the nurse administer the medication? a. In the IV line for the blood product during the transfusion b. In the IV line for the blood product when the line is flushed with normal saline c. In oral form d. Through another IV line

d. Through another IV line The nurse would maintain a separate access line if IV solutions or medications are to be administered. Medication is never injected into the same IV line used for a blood component. The blood product may be incompatible with the medication, and the blood component could become contaminated if the same IV line is used for another purpose.

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 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.