Blood Transfusion NCLEX
"The client with O+ blood is in need of an emergency transfusion but the lab does not have any O+ blood available. Which potential unit of blood could be given to the client? "1. 0- unit 2. A+ unit 3. B+ unit 4. Any Rh+ unit"
"Correct answer: Answer 1. 1. 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 anti-gens 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 anti-bodies. 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 a massive hemolysis of the client's blood and death."
The nurse has received a prescription to transfuse a client with a unit of packed red blood cells. Before explaining the procedure to the client, the nurse should ask which INITIAL question? 1) "Have you ever had a transfusion before?" 2) "Why do you think that you need the transfusion?" 3) "Have you ever gone into shock for any reason in the past?" 4) "Do you know the complications and risks of a transfusion?"
1) "Have you ever had a transfusion before?" Rationale: Asking the client about personal experience with transfusion therapy provides a good starting point for client teaching about this procedure. Questioning about previous history of shock and knowledge of complications and risks of transfusion are not helpful because they may elicit a fearful response from the client. Although determining whether the client knows the reason for the transfusion is important, it is not an appropriate statement in terms of eliciting information from the client regarding an understanding of the need for the transfusion.
A client requiring surgery is anxious about the possible need for a blood transfusion during or after the procedure. The nurse suggests to the client to take which action(s) to reduce the risk of possible transfusion complications? SELECT ALL THAT APPLY. 1) Ask a family member to donate blood ahead of time. 2) Give an autologous blood donation before the surgery. 3) Take iron supplements before surgery to boost hemoglobin levels. 4) Request that any donated blood be screened twice by the blood bank. 5) Take adequate amounts of vitamin C several days prior to the surgery date.
1) Ask a family member to donate blood ahead of time. 2) Give an autologous blood donation before the surgery. Rationale: A donation of the client's own blood before a scheduled procedure is autologous. Donating autologous blood to be reinfused as needed during or after surgery reduces the risk of disease transmission and potential transfusion complications. The next most effective way is to ask a family member to donate blood before surgery. Blood banks do not provide extra screening on request. Preoperative iron supplements are helpful for iron deficiency anemia but are not helpful in replacing blood lost during the surgery. Vitamin C enhances iron absorption, but also is not helpful in replacing blood lost during surgery.
The nurse who is about to begin a blood transfusion knows that blood cells start to deteriorate after a certain period of time. Which item is important to check regarding the age of blood cells before the transfusion is begun? 1) Expiration date 2) Presence of clots 3) Blood group and type 4) Blood identification number
1) Expiration date Rationale: The nurse notes the expiration date on the unit of blood to ensure that the blood is fresh. Blood cells begin to deteriorate over time, so safe storage is usually limited to 35 days. Careful notation of the expiration date by the nurse is an essential part of the verification process before hanging a unit of blood. The nurse also notes the blood identification (unit) number, blood group and type, and client's name. The nurse also inspects the unit of blood for leaks, abnormal color, clots, and bubbles and returns the unit to the blood bank if clots are noted.
A client receiving a transfusion of packed red blood cells (PRBCs) begins to vomit. The client's blood pressure is 90/50 from a baseline of 125/78. The client's temperature is 100.8F orally from a baseline of 99.2F orally. The nurse determines that the client may be experiencing which complication of a blood transfusion? 1) Septicemia 2) Hyperkalemia 3) Circulatory overload 4) Delayed transfusion reaction
1) Septicemia Rationale: Septicemia occurs with the transfusion of blood contaminated with microorganisms. Signs include CHILLS, FEVER, VOMITING, DIARRHEA, HYPOTENSION, and the development of SHOCK. Hyperkalemia causes weakness, paresthesias, abdominal cramps, diarrhea, and dysrhythmias. Circulatory overload causes cough, dyspnea, chest pain, wheezing, tachycardia, and hypertension. A delayed transfusion reaction can occur days to years after a transfusion. Signs include fever, mild jaundice, and a decreased hematocrit level.
The nurse has obtained a unit of blood from the blood bank and has checked the blood bag properly with another nurse. Just before beginning the transfusion, the nurse should assess which PRIORITY item? 1) Vital signs 2) Skin color 3) Urine output 4) Latest hematocrit level
1) Vital signs Rationale: A change in vital signs during the transfusion from baseline may indicate that a transfusion reaction is occurring. This is why the nurse assesses vital signs BEFORE the procedure and again after the first 15 minutes. The other options do not identify assessments that are a priority just before beginning a transfusion.
A client has a prescription to receive a unit of packed red blood cells. The nurse should obtain which intravenous (IV) solution from the IV storage area to hang with the blood product at the client's bedside? 1) Lactated Ringer's 2) 0.9% sodium chloride 3) 5% dextrose in 0.9% sodium chloride 4) 5% dextrose in 0.45% sodium chloride
2) 0.9% sodium chloride Rationale: Sodium chloride 0.9% (normal saline) is a standard isotonic solution used to precede and follow infusion of blood products. Dextrose is not used because it could result in clumping and subsequent hemolysis of red blood cells. Lactated Ringer's is not the solution of choice with this procedure.
The nurse has just received a prescription to transfuse a unit of packed red blood cells for an assigned client. Approximately how long will the nurse need to stay with the client to ensure that a transfusion reaction is not occurring? 1) 5 minutes 2) 15 mintues 3) 30 minutes 4) 45 mintues
2) 15 mintues Rationale: The nurse must remain with the client for the first 15 minutes of a transfusion, which is usually when a transfusion reaction may occur. This enables the nurse to detect a reaction and intervene quickly.
Following infusion of a unit of packed red blood cells, the client has developed new onset of tachycardia, bounding pulses, crackles, and wheezes. Which action should the nurse implement FIRST? 1) Maintain bed rest with legs elevated 2) Place the client in high-Fowler's position 3) Increase the rate of infusion of intravenous fluids 4) Consult with the HCP regarding initiation of oxygen therapy.
2) Place the client in high-Fowler's position Rationale: New onset of tachycardia, bounding pulses, crackles and wheezes post-transfusion are evidence of fluid overload, a complication associated with blood transfusions. Placing the client in a high-Fowler's (upright) position will facilitate breathing. Measures that increase blood return to the heart, such as leg elevation and administration of intravenous fluids, should be avoided at this time. In addition, administration of fluids cannot be initiated without a prescription. Consulting with the HCP regarding administration of oxygen may be necessary, but positional changes take a short amount of time to do and should be initiated first.
A client is brought to the emergency department having experienced blood loss related to an arterial laceration. Fresh-frozen plasma is prescribed and transfused to replace fluid and blood loss. The nurse understands that which is the rationale for transfusing fresh-frozen plasma to this client? 1) To treat the loss of platelets 2) To promote rapid volume expansion 3) Because a transfusion must be done slowly 4) Because it will increase the hemoglobin and hematocrit levels
2) To promote rapid volume expansion Rationale: Fresh-frozen plasma is often used for volume expansion as a results of fluid and blood loss. It does not contain platelets, so it is not used to treat any type of low platelet count disorder. It is rich in clotting factors and can be thawed quickly and transfused quickly. It will not specifically increase the hemoglobin and hematocrit level.
The nurse has just received a unit of packed red blood cells from the blood bank for transfusion to an assigned client. The nurse is careful to select tubing especially made for blood products, knowing that this tubing is manufactured with which item? 1) An air vent 2) Tinted tubing 3) An in-line filter 4) A microdrip chamber
3) An in-line filter Rationale: The tubing used for blood administration has an in-line filter. The filter helps ensure that any particles larger than the size of the filter are caught in the filter and are not infused into the client. Tinted tubing is incorrect because blood does not need to be protected from light. The tubing should be macrodrip, not microdrip, to allow blood to flow freely through the drip chamber. An air vent is unnecessary because the blood bag is not made of glass.
Packed red blood cells have been prescribed for a client with low hemoglobin and hematocrit levels. The nurse takes the client's temperature before hanging the blood transfusion and records 100.6 F orally. Which action should the nurse take? 1) Begin the transfusion as prescribed. 2) Administer an antihistamine and begin the transfusion. 3) Delay hanging the blood and notify the health care provider. 4) Administer two tablets of acetaminophen (Tylenol) and begin the transfusion.
3) Delay hanging the blood and notify the health care provider. Rationale: If the client has a temperature higher than 100 F, the unit of blood should not be hung until the HCP is notified and has the opportunity to give further prescriptions. The HCP likely will prescribe that the blood be administered regardless of the temperature, but the decision is not within the nurse's scope of practice to make. The nurse needs an HCP's prescription to administer medications to the client.
The nurse determines that a client is having a transfusion reaction. After the nurse stops the transfusion, which action should be taken NEXT? 1) Remove the intravenous (IV) line. 2) Run a solution of 5% dextrose in water. 3) Run normal saline at a keep-vein-open rate. 4) Obtain a culture of the tip of the catheter device removed from the client.
3) Run normal saline at a keep-vein-open rate. Rationale: If the nurse suspects a transfusion reaction, the nurse stops the transfusion and infuses normal saline at a keep-vein-open rate pending further health care provider prescriptions. This maintains a patent IV access line and aids in maintaining the client's intravascular volume. The nurse would NOT remove the IV line because then there would be no IV access route. Obtaining a culture of the tip of the catheter device removed from the client is incorrect. First, the catheter should NOT be removed. Second, cultures are performed when infection, NOT transfusion reactions, is suspected. Normal saline is the solution of choice over solutions containing dextrose because saline does not cause red blood cells to clump.
A client with severe blood loss resulting from multiple trauma requires rapid transfusion of several units of blood. The nurse asks another health team member to obtain which device for use during the transfusion procedure to help reduce the risk of cardiac dysrhythmias? 1) Infusion pump 2) Pulse oximeter 3) Cardiac monitor 4) Blood-warming device
4) Blood-warming device Rationale: If several units of blood are to be administered, a blood warmer should be used. Rapid transfusion of cool blood places the client at risk for cardiac dysrhythmias. To prevent this, the nurse warms the blood with a blood-warming device. Pulse oximetry and cardiac monitoring equipment are useful for the early assessment of complications but do not reduce the occurrence of cardiac dysrhythmias. Electronic infusion devices are not helpful in this case because the infusion must be rapid, and infusion devices generally are used to control the flow rate. In addition, not all infusion devices are made to handle blood or blood products.
The client has received a transfusion of platelets. The nurse evaluates that the client is benefiting most from this therapy if the client exhibits which finding? 1) Increased hematocrit level 2) Increased hemoglobin level 3) Decline of elevated temperature to normal 4) Decreased oozing of blood from puncture sites and gums
4) Decreased oozing of blood from puncture sites and gums Rationale: Platelets are necessary for proper blood clotting. The client with insufficient platelets may exhibit frank bleeding or oozing of blood from puncture sites, wounds, and mucous membranes. Increased hemoglobin and hematocrit levels would occur when the client has received a transfusion of red blood cells. An elevated temperature would decline to normal after infusion of granulocytes if those cells were instrumental in fighting infection in the body.
The nurse, listening to the morning report, learns that an assigned client received a unit of granulocytes the previous evening. The nurse makes a note to assess the results of which daily serum laboratory studies to assess the effectiveness of the transfusion? 1) Hematocrit level 2) Erythrocyte count 3) Hemoglobin level 4) White blood cell count
4) White blood cell count Rationale: The client who has neutropenia may receive a transfusion of granulocytes, or white blood cells. These clients often have severe infections and are unresponsive to antibiotic therapy. The nurse notes the results of follow-up white blood cell counts and differential to evaluate the effectiveness of the therapy. The nurse also continues to monitor the client for signs and symptoms of infection. Erythrocyte count and hemoglobin and hematocrit levels are determined after transfusion of packed red blood cells.
The nurse has discontinued a unit of blood that was infusing into a client because the client experienced a transfusion reaction. After documenting the incident appropriately, the nurse sends the blood bag and tubing to which of the following departments? a. Blood bank b. Risk management c. Environmental services d. Infection control
A. blood bank The nurse returns the blood transfusion bag containing any remaining blood to the blood bank. This allows the blood bank to complete any follow-up testing procedures needed once a transfusion reaction has been documented. The other option identify incorrect departments.
"The nurse receives a physician's order to transfuse fresh frozen plasma to a patient suffering from an acute blood loss. Which of the following procedures is most appropriate for infusing this blood product? A. Infuse the fresh frozen plasma as rapidly as the patient will tolerate. B. Hang the fresh frozen plasma as a piggyback to the primary IV solution. C. Infuse the fresh frozen plasma as a piggyback to a primary solution of normal saline. D. Hand the fresh frozen plasma as a piggyback to a new bag of primary IV solution without KCl."
Correct A "The fresh frozen plasma should be administered as rapidly as possible and should be used within 2 hours of thawing. Fresh frozen plasma is infused using any straight-line infusion set. Any existing IV should be interrupted while the fresh frozen plasma is infused, unless a second IV line has been started for the transfusion."
The client has a hematocrit of 22.3% and a hemoglobin of 7.7 mg/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
Correct: 1, 3, 4
A 52-year-old woman is admitted with a new diagnosis of gastrointestinal (GI) bleed. The physician has ordered the client to receive 2 units of packed red blood cells (PRBCs) for a hemoglobin (Hgb) of 6.8g/dL. The nurse begins the infusion of the first unit at 100mL/hr. Firfteen minutes after the start of the infusion, the client complains that she is feeling chilled, is short of breath, and is experiencing lumbar pain rated 8 on a 1-10 scale. Whic of the following should be the nurse's FIRST action. "1. Obtain vital signs and notify the physician of potential reaction 2. Slow the infusion to 75mL/hr and reassess in 15 minutes 3. Stop the infusion and run normal saline (NS) to keep the vein open (KVO) 4. Administer PRN pain medication as ordered, apply oxygen at 2 L/min, and provide an additional blanket"
Correct: 3 "1. ""Obtain vital signs..."" - vital sings should be obtained, and the physician notified after treatment is discontinue. The unit in quesiton should not be restarted, and any other units that were issued should not be implemented. 2. ""Slow the infusion..."" - just slowing the infusino will not resolve the issue of an allergic reaction to the treatment 3. ""Stop the infusion..."" - (CORRECT): The symptoms of feeling chilllded, being short of breath, and having back pain coudl indicate an acute hemolytic reaction. This medical emergency requires swift action on the part of the nurse, including immediately discontinuing the infusion, flushing the IV site, and saving the unit of blood in question for testing. 4. ""Administer PRN pain medication..."" - Treating the symptoms of the reaction will not resolve the issue of an allergic reactio to the treatment"
The nurse enters a client's room to assess the client, who began receiving a blood transfusion 45 minutes earlier, and notes that the client is flushed and dyspneic. On assessment, the nurse auscultates the presence of crackles in the lung bases. The nurse determines that this client most likely is experiencing which complication of blood transfusion therapy? 1) Bacteriemia. 2) Hypovolemia. 3) Fluid overload 4) Transfusion reaction
Correct: 3?? 4 With fluid overload, the client has the presence of crackles in addition to dyspnea. An allergic reation, a type of blood transfusion reaction, would produce symptoms such as flushing, dyspnea, itching, and a generalized rash. Hypovolemia is not complication of blood transfusions. With bacteriemia, the client would have fever, a symptom not presented.
"The nurse understands that the client with pernicious anemia will have which distinguishing laboratory findings? "a. Schilling's test, elevated b. Intrinsic factor, absent. c. Sedimentation rate, 16 mm/hour d. RBCs 5.0 million
Correct: B ANSWER B. The defining characteristic of pernicious anemia, a megaloblastic anemia, is lack of the intrinsic factor, which results from atrophy of the stomach wall. Without the intrinsic factor, vitamin B12 cannot be absorbed in the small intestines, and folic acid needs vitamin B12 for DNA synthesis of RBCs.
"A month after receiving a blood transfusion an immunocompromised male patient develops fever, liver abnormalities, a rash, and diarrhea. The nurse would suspect this patient has: a. Nothing related to the blood transfusion b. Graft-versus-host disease (GVHD) c. Myelosuppression d. An allergic response to a recent medication"
Correct: B GVHD occurs when white blood cells in donor blood attack the tissues of an immunocompromised recipient. This process can occur within a month of the transfusion. Options 1 and 4 may be a thought, but the nurse must remember that immunocompromised transfusion recipients are at risk for GVHD
A new RN is preparing to administer packed red blood cells (PRBCs) to a client whose anemia was caused by blood loss after surgery. Which action by the new RN requires that you, as charge nurse, intervene immediately? "a. The new RN waits 20 minutes after obtaining the PRBCs before starting the infusion. b. The new RN starts an intravenous line for the transfusion using a 22-gauge catheter. c. The new RN primes the transfusion set using 5% dextrose in lactated Ringer's solution. d. The new RN tells the client that the PRBCs may cause a serious transfusion reaction."
Correct: C ANSWER C - Normal saline, an isotonic solution, should be used when priming the IV line to avoid causing hemolysis of RBCs. Ideally, blood products should be infused as soon as possible after they are obtained; however, a 20-minute delay would not be unsafe. Large-gauge IV catheters are preferable for blood administration; if a smaller catheter must be used, normal saline may be used to dilute the RBCs. Although it is appropriate to instruct clients to notify the nurse if symptoms of a transfusion reaction such as shortness of breath or chest pain occur, it will cause unnecessary anxiety to indicate that a serious reaction is likely to occur. Focus: Prioritization
"Which organ is at greatest risk due to the effects of hemolytic anemia? "A. Heart B. Spleen C. Kidney D. Liver
Correct: C For all causes of hemolysis, a major focus of treatment is to maintain renal function. When RBCs are hemolyzed, the hemoglobin molecule is released and filtered by the kidneys. The accumulation of hemoglobin molecules can obstruct the renal tubules and lead to acute tubular necrosis
"The nurse is caring for a patient who is to receive a transfusion of two units of packed red blood cells. After obtaining the first unit from the blood bank, the nurse would ask which of the following health team members in the nurses' station to assist in checking the unit before adiminstration? A: Unit Secretary B: A Phlebotomist C: A Physician's Assistant D: Another Registered Nurse
Correct: D Before hanging a transfusion, the registered nurse must check the unit with ANOTHER RN or with a licensed practical (vocational) nurse, depending on agency policy. Checking blood products is not in the unit secretary's or phlebotimist's scope of practice. The physician assistant is not another RN or licensed practical nurse.
"Complications of transfusions that can be decreased by the use of leukocyte depletion or reduction of RBC transfusion are a. chills and hemolysis. b. leukostasis and neutrophilia. c. fluid overload and pulmonary edema. d. transmission of cytomegalovirus and fever.
Correct: D Rationale: Infectious viruses, such as human immunodeficiency virus (HIV), human herpesvirus, hepatitis B and C type 6 (HSV-6), Epstein-Barr virus (EBV), human T-cell leukemia virus type 1 (HTLV-1), and cytomegalovirus (CMV), and other agents, such as the agent that causes malaria, can be transmitted by blood transfusion. Leukocyte-reduced blood products drastically reduce the risk of blood transfusion-associated viral infections, including CMV.
About ten minutes after the nurse begins an infusion of packed RBCs, the patient complains of chills, chest and back pain, and nausea. His face is flushed, and he's anxious. Which is the priority nursing action? 1. Administering antihistamines STAT for an allergic reaction. 2. Notifying the physician of a possible transfusion reaction. 3. Obtaining a urine and serum specimen to send to the lab immediately. 4. Stopping hte transfusion and maintaining a patent IV catheter."
The correct answer is 4. The patietn is experiencing a transfusion reaction. The immediate nursing action is to stop the transfusion and maintain a patent IV line. The other options may be indicated but aren't the priority in this case.
A nurse has an order to transfuse a unit of packed red blood cells to a client who does not currently have an IV line inserted. When obtaining supplies to start the IV infusion the nurse selects an angiocatheter with a size of: a. 18 gauge b. 21 gauge c. 22 gauge d. 24 gauge
a. 18 gauge The IV catheter used for a blood transfusion should be at least 18 or 19 gauge. Compared with IV solutions, blood has a thicker and stickier consistency, and use of an 18 or 19 gauge catheter will ensure that the bore of the catheter is large enough to prevent damage to the blood cells.
The nurse is picking up a unit of packed red blood cells at the hospital blood bank. After putting the pen down, the nurse glances at the clock, which reads 1:00. The nurse calculates that the transfusion must be started by: a. 1:30 b. 2:00 c. 2:30 d. 3:00
a. 1:30 Blood must be hung as soon as possible within 30 mintues after it is obtained from the blood bank.
A client has experienced a rash with pruritus during previous blood transfusions. The client asks the nurse whether it is safe to receive another transfusion. In formulating a response, the nurse incorporates the understanding that which medication will most likely be prescribed before the transfusion is begun? a. Ibuprofen (Motrin) b. Acetaminophen (Tylenol) c. Diphenhydramine (Benadryl) d. Acetylsalicylic Acid (ASA Aspirin)
c. Diphenhydramine (Benadryl) An urticarial reaction is characterized by a rash accompanied by pruritus. This type of transfusion reaction is prevented by pretreating the client with an antihistamine such as diphenhydramine. Acetaminophen and ASA are analgesics and ibuprofen is a NSAID