Mobility Nursing: Blood Transfusion

hypovolemic shock

Blood volume drops. Vital signs: hypotension, tachycardia. First sign: pale and restless. Decreased cerebral perfusion, reduction in cardiac output, sunken eyeballs, tachypnea, flattened neck veins, blood shunting away from major organs

nuring diagnosis

Acute pain Anxiety Decrease cardiac output Excess fluid volume Hyperthermia Hypothermia Impaired gas exchange Risk of infection

The nurse who is about to give a blood transfusion knows that blood cells start to deteriorate after a certain period of time. Which of the following items is important to check regarding the age of blood cells before the transfusion is begun? A. Expiration date B. Presence of clots C. Blood group and type D. Blood identification number

Correct A

blood admisitration

initiate within 30 minutes of leaving blood bank check sexpiration date, gently agitate must match number on american red cross number Check with 2 RN's, one of which will be administering blood. Check that blood product delivered is what the MD ordered. Restate symptoms of reaction to patient with administration of each unit.

starting transfusion

ALLOW ONLY 10-20 ML FOR FIRST 15 MINUTES, talk with pt Wash hand and don gloves. Prime blood tubing with NS. Close clamps. Attach blood product by inserting spike of Y tubing located next to NS. Close clamp above NS & open clamp above blood product and start transfusion slowly. Allow only 10-20 ml to infuse in the first 15 minutes. Patient will be monitored closely for a reaction during the initial 15 minutes. If no reaction within the first 15 minutes, adjust rate of infusion according to MD order. Follow hospital policy to monitor vital signs. Most policies VS 15, 30 and 60 minutes and then when blood completed must administer blood unit within 4 hours. usually rate of 100cc per hour

The nurse is caring for a 70-year-old client with hypovolemia who is receiving a blood transfusion. Assessment findings reveal crackles on chest auscultation and distended neck veins. What is the nurse's initial action? A. Slow the transfusion. B. Document the finding as the only action. C. Stop the blood transfusion and turn on the normal saline. D. Assess the client's pupils.

Answer A is correct. The client is exhibiting symptoms of fluid volume excess; slowing the rate is the proper action. The nurse would not stop the infusion of blood, as in answer C, and answers B and D would not help.

Bad sign of transfusion S/S

chills, dizziness, fever, low back pain, flushing, tachycardia, tachypnea, hypotension, itching, urticaria (hives), headache, anxiety, muscle pain, wheezing, dyspnea, cough, crackles must make patient aware but not need to go over everything

During a blood transfusion a client develops chills and a headache, what is the priority nursing action A) cover the client B) stop the transfusion at once C) notify the physician immediately D) decrease the rate of blood infusion

B) stop the transfusion because chills, headache, and nausea are all signs of transfusion reaction

Following surgery, the client requires a blood transfusion. The main reason the nurse wants to complete the unit transfusion within a 4-hour period is that blood: A. Hanging for a longer then 4 hours creates an increased risk of sepsis B. May clot in the bag C. May evaporate D. May not clot in the recipient after this time period

Correct A Hanging for a longer four hours creates an increased risk of sepsis, which is why the nurse wants to complete the unit transfusion in less than four hours. The remaining items are not likely to happen.

The client is admitted to the ED after an MVA. The nurse notes profuse bleeding from a right-sided abdominal injury. Which intervention should the nurse implement first? 1.) Type and crossmatch for RBCs 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.

Correct: 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 1.) This should be done, but the client requires the IV fluids first because they are at risk for shock. 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.

A client brought to the emergency department states that he has accidentally been taking two times his prescribed dose of warfarin (Coumadin) for the past week. After noting that the client has no evidence of obvious bleeding, the nurse plans to do which of the following? 1. Prepare to administer an antidote. 2. Draw a sample for type and crossmatch and transfuse the client. 3. Draw a sample for an activated partial thromboplastin time (aPTT) level. 4. Draw a sample for prothrombin time (PT) and international normalized ratio (INR).

Correct: 4

acute intravascular hemolytic clinical manifestations

Low back/flank pain Fever/chills Dyspnea Tachycardia Tachypnea Headache Hypotension hemoglobinuria Hemoglobinemia Sudden oliguria Anxiety Chest pain/tightness Bronchospasm Circulatory shock Death

urticarial/ mild allergic clinical manifestation

Puritis Rash Itching Uriticaria (hives) Flushing

autologous blood

Collection and reinfusion of patients own blood. Obtained preoperative for elective surgery. Eliminates disease transmission. Eliminates risk of immune mediated transfusion reaction. can be expensive to store. done up to 6 weeks before surgery. Ex: heart surgery, orthopedic, plastic, or gynecological

The nurse is aware that the following solutions is routinely used to flush an IV device before and after the administration of blood to a patient is: a. 0.9 percent sodium chloride b. 5 percent dextrose in water solution c. Sterile water d. Heparin sodium

Correct: A 0.9 percent sodium chloride is normal saline. This solution has the same osmolarity as blood. Its use prevents red cell lysis. The solutions given in options 2 and 3 are hypotonic solutions and can cause red cell lysis. The solution in option 4 may anticoagulate the patient and result in bleeding.

Laboratory studies for blood transfusion

HH-low levels (ex: bleeding, blood loss from surgery) INR-supratherapeutic level (level to high, making blood thin) Platelets-thrombocytopenia (low platelets) Type and Screen-determines both the ABO and the Rh of the patient to determine the blood type. Performed on persons who may need a transfusion of any type of blood product Type and Crossmatch-performed prior to blood transfusion in order to determine if the blood is compatible with the blood of an intended recipient.

preparation for blood transfusion

IV access- need large gauge catheter (18-20 gauge). Solution compatibility-only 0.9% Normal Saline (NS) IV pole Blood administration set, Y tubing & filter. Roller clamp -shut both lines of Y check iv site before! BLOOD ALWAYS GO IN BY ITSELF NO MEDICATION, ONLY NORMAL SALINE ALLOWED. retrieving blood Nurses Aids or Operating Room Technicians are permitted to retrieve blood products from the lab in many institutions special tubing used to transfusion.

outcome from transfusion

In a non bleeding adult, one unit of packed red blood cells (PRBC's) should increase the hemoglobin by 1g/dl and hematocrit by 3 percentage points Ex: Hgb/Hct (H/H)—9/27 before transfusion After transfusion: 10/30 If H/H does not go up the pateint could be bleeding somewhere or lab done at wrong time. Example: GI bleed loss of blood= bloody stools. if giving patient alot of fluids, dilutes blood

religious considerations

Jehovah Witnesses refuse to accept blood. There may be exceptions to this (for example, you cannot say that all Catholics do not eat meat on Fridays). Muslims may accept blood if it means survival. Don't be afraid to ask the patient about their beliefs! Parents may be taken to court if a child needs blood (this does not mean that the hospital will win the case).

blood salvage/ autologous transfusion

Replacing blood volume by collecting, filtering and returning the patient's own blood lost during a major surgical procedure. After surgery blood is salvaged from a patient. Commonly done in orthopedic surgeries. Most common system requires collecting the blood within a timeframe and then reinfusing it, keeping within parameters to prevent infection. This is safer for patients because they are receiving their own blood back can save blood in hemovac

safe transfusion protocol

Review Hospital policy regarding blood transfusions Hemoglobin/Hematocrit (H/H) levels indicated for transfusion Must be administered by RN, witnessed by a second nurse. Ordered by the MD or Mid-Level, need to discuss the risks, benefits, and alternatives with the patient and document this is the medical record: should have physician speak to patient about risk/ benefits. sometimes the nurse might have to go over it again. Never regard a blood transfusion as routine Overlooking a minor detail may be life threatening Patient safety is nursing priority

sepsis signs and symptoms

Signs/symptoms: High fever Chills (Rapid onset) Profound hypotension Abdominal cramps Renal failure Vomiting Diarrhea Oliguria Disseminated intravascular coagulation (DIC)

circulatory overload treatment

Stop transfusion Notify MD Monitor vital signs and output Treat symptoms KVO Fowlers position Administer oxygen, diuretics, and morphine as ordered. Stat chest x-ray if ordered Implement meds as ordered Return blood to lab or as ordered

acute intravascular hemolytic management

Stop transfusion! KVO new NS set-up Notify MD/institute treatment as ordered Monitor VS every 15 min Strict I & O every hour Obtain blood slowly to avoid hemolysis/urine specimen Return blood/tubing to lab. Document dialysis may be needed if acute kidney injury occurs Do not transfuse additional RBC containing components until new cross match depending on reaction may need rapid response

patient safety for transfusion

The blood components delivered are the ones that were ordered. Blood being delivered is compatible with the blood type listed on the blood type on medical record (Type and Cross match). The right patient is receiving the blood.

The nurse is preparing to administer a blood transfusion of PRBCs. The correct solution to use to flush the tubing when administering a blood transfusion is: A. 5% dextrose in water (D5W). B. Lactated Ringer's solution (LR). C. 0.9% NaCl (normal saline) solution D. Plasmalyte-A

Correct C The correct answer is normal saline. Normal saline is the only solution used to flush the tubing during a blood transfusion. The other solutions listed aren't indicated and may hemolyze the RBCs.

Sepsis

Rare, but can occur anytime during procurement or processing. Bacterial contamination of transfused blood components. Gram negative bacteria can be blood sitting out too long

Indication for transfusion needed clinical factors and signs

Treat and restore homodynamic homeostasis due to... 1. Anemia H/H less than 8.0 g/dl/24% (Symptomatic patients) H/H less than 7.0 g/dl/21% (Stable hospitalized patients) Check Hospital Guidelines. 2. Documented symptoms of hypovolemic shock 3. Blood loss greater than 750 ml 4. Surgical procedure blood loss 5. Sickle cell anemia crisis 6. Any Hgb or Hct where clinical distress or ischemia directly attributable to decrease oxygen carrying capacity. 7. Chemotherapy

The physician orders 2 units of packed RBCs to be administered to the client. At 0600 the night shift nurse initiates the first unit's transfusion before going off shift. At 1000 the day shift nurse notes the IV line has clotted off and the transfusion has not been completed. The nursing assessment revealed the transfusion was only approximately 75% complete. Which of the actions by the nurse is most appropriate? A. Advise the blood bank about the delay for the next unit. B. Restart another peripheral line with 0.9% NS and restart the blood transfusion with the remaining blood unit. C. Discontinue the transfusion. D. Document the amount infused thus far and continue the transfusion.

Answer C Rationale: A unit of blood should be administered within a 4 hour period of time. The nurse should discontinue the transfusion, document the findings and notify the blood bank. The agency policy will need to be followed concerning the documentation process and notification of appropriate personnel. Continuing the transfusion with the "open" unit will expose the client to an increase risk of injury.

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

urticarial/ mild allergic cause

Occurs frequently (1-3%). Cause: Antibodies against donor plasma proteins Common in people with history of allergies.

Components of whole blood

Packed Red Blood Cells (PRBC) Platelets Fresh Frozen Plasma (FFP) Albumin Cryoprecipitates

incompatibilty of transfusion

Results in hemolysis: Destruction of RBC cell membrane through antibody mediated lysis. people have died from this. in the beginning run blood very slowly What is hemoglobinuria? blood in urine

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 patient 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.

management of transfusion reaction

Use appropriate blood administration set. Document procedure with another RN. STOP the transfusion if you suspect or detect a reaction Change the IV tubing down to the site KVO with 0.9% normal saline (0.9%NS) Notify MD/monitor VS Observe for circulatory overload with patients at risk Replace filter set with each transfusion. Document that a transfusion reaction occurred Follow hospital protocol

The nurse is preparing to initiate a blood transfusion. The client has a peripheral intravenous infusion in their left arm that the physician has ordered not be slowed or rate reduced. The nurse prepares to start another line in the right arm. The client asks the nurse to use the existing site to avoid the trauma of having another line started. Which of the following statements by the nurse is correct? A. "That will be fine" B. "I will need to infuse the blood through a separate IV line." C. "I will let the physician know about your preferences." D. "We will need to assess the line before I can make a determination about your request."

Answer: B Rationale: A blood infusion must be administered via a separate IV line. The other responses indicate to the client their request is being considered

Halfway through the administration of blood, the female client complains of lumbar pain. After stopping the infusion the nurse should: a. Increase the flow of normal saline b. Assess the pain further c. Notify the blood bank d. Obtain vital signs.

Correct A The blood must be stopped at once, and then normal saline should be infused to keep the line patent and maintain blood volume.

The nurse has obtained a unit of blood from the blood bank and has checked the blood bag properly with another nurse. Just before the beginning transfusion, the nurse assesses which of the following items? A. Vital signs B. Skin Color C. Urine ouput D. Latest hematocrit level.

Correct Answer A Change in vital signs during the transfusion from the baseline may indicate that a transfusion reaction is occuring. This is why nurse assesses vital signs before the procedure and again after 15 mintues. The other options do not identify assessment that are required just before beginning a transfusion.

A child with beta-thalassemia is receiving long-term blood transfusion therapy for the treatment of this disorder. Chelation therapy is prescribed to prevent organ damage from the presence of too much iron in the body as a result of the transfusions. Which of the following medications would the nurse anticipate to be prescribed in chelation therapy? 1. Meopenem (Merrem) 2. Metoprolol (Toprol-XL) 3. Deferoxamine (Desferal) 4. Dalteparin sodium (Fragmin)

Correct answer: 3. Deferoxamine (Desferal) Rationale: Beta-Thalassemia is an autosomal recessive disorder characterized by the reduced production of one of the globin chains in the synthesis of hemoglobin (both parents must be carriers to produce a child with Beta-Thalassemia major). The major complication of long-term transfusion therapy is hemosiderosis. To prevent organ damage from too much iron, chelation therapy with either deferasirox (Exjade) or deferoxamine (Desferal) may be prescribed. Deferoxamine is classified as an antidote for acute iron toxicity. Dalteparin is an anticoagulant used as prophylaxis for postoperative DVT. Meropenem is an antibiotic. Metoprolol is a Beta-blocker used to treat HTN.

A 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 asks which initial questions? 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?

Correct: 1 Asking the client about personal experience with tranfusion therapy provides a good starting point for client teaching about this procedure. Options 3 & 4 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, option 2 is not an appropriate statement in terms of eliciting information from the client regarding an understanding of the need for the transfusion.

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 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.

A unit of packed red blood cells has been prescribed for a client with low hemoglobin and hematocrit levels. The nurse notifies the blood bank of the order, and a blood specimen is drawn from the client for typing and cross-matching. The nurse receives a telephone call from the blood bank and is informed that he unit of blood is ready for administration. Arrange the actions in order of priority that the nurse should take to administer the blood. (Letter A is the first and letter F is the last action.) a) hang the bag of blood b) obtain the unit of blood from the bank c) ensure that an informed consent has been signed d) verify the physician's order for the blood transfusion e) insert an 18 or 19-gauge IV catheter into the client f) ask a licensed nurse to assist in confirming blood compatibility and verifying client identity.

D, C, E, B, F, A First verify the physician's order for the blood transfusion Ensure that the client has been informed about the procedure and has signed an informed consent. Next, ensure that at least an 18- or 19-gauge intravenous needle is inserted into the client. Blood has a thicker and stickier consistency than intravenous solutions and using an 18- or 19-gauge catheter ensures that the bore of the catheter is large enough to prevent damage to the blood cells. Next, the blood is obtained from the blood bank, once the nurse is sure that the client has been informed and has an adequate access for administering the blood. Next, two registered nurses, or one registered and a licensed practical nurse (depending on agency policy), must together check the label on the blood product against the client's identification number, blood group, and complete name. This minimizes the risk of error in checking information on the blood bag and thereby minimizes the risk of harm or injury to the client. The nurse should measure vital signs and assess lung sounds Last, hang the transfusion.

acute intravascular hemolytic causes and prevention

Most serious, life threatening! Usually occurs within first few minutes. Cause: ABO, Rh incompatibility; causes intravascular destruction of RBC's. more than 10 mL RBC Prevention : Meticulous verification and documentation of patient identification from sample collection to component infusion.

anaphylactic cause and prevention

Rare but serious, potentially life threatening. Allergic antigen/antibody reaction Allergy to donor plasma antigen, especially anti-IgA. Anaphylaxis NOT caused by RBC incompatibility Occur in first few ml of transfusion, 5-15 minutes Prevention Transfuse with extensively washed RBC products from which all plasma has been removed. Alternate use blood from IgA-deficient donor.

Documentation

Record amount of blood transfused. Document vital signs at appropriate times Record time blood started & ended Record any transfusion reactions. Nurse signature of all documents Distribute paper work as directed. Monitor and record patient condition frequently during transfusion Monitor IV site frequently Remove and dispose of blood administration tubing. Tubing is single use and not to be reused for multiple units. Following hospital protocol for disposal. dispose in bio hazard

febrile non hemolytic management

Stop Transfusion Give antipyretics as prescribed. Avoid aspirin in patients with thrombocytopenia. Do not restart transfusion. Continue to monitor temperature Prevention Consider leukocyte-poor blood products (filtered, washed, or frozen). Give antipyretics or diphenhydramine - 30 minutes prior to transfusion. if patient has a prior history of reaction EX: tylenol, benadryl .

A client receiving a transfusion of packed red blood cells begins to vomit. The client's blood pressure is 90/50 from a baseline of 125/78. Temp is 100.8 from baseline 99.2 orally. The nurse determines patient is experiencing which complication with blood transfusion? A. septicemia B. hyperkalemia. C. circulatory overload. D. Delayed tranfusion reaction.

A, septicemia occurs with transfusion of blood contaminated with microorganisms. Signs include chills, fever, vomiting, diarrhea, hypotension, and development of shock. Hyerkalemia causes weakness, paresthesia, abdominal cramps, diarrhea, and dysrythmias. Circulatory overload causes cough, dyspnea, chest pain, wheezing, tachycardia, and hypertension. Delayed transfusion reaction can occer days or weeks after transfuison. Signs include fever, mild jaundice, and a decrease hematocrit level.

circulatory overload signs and symptoms

Blood Administered faster than circulation can accommodate. Signs/symptoms: Cough Dyspnea Orthopnea Crackles Productive cough with pink frothy sputum Tachycardia Hypertension Distended neck veins Headache

Cris asks the nurse whether all donor blood products are cross-matched with the recipient to prevent a transfusion reaction. Which of the following always require cross-matching? a. packed red blood cells b. platelets c. plasma d. granulocytes

Correct: A & C

pre-administration protocol

Informed consent signed by MD and patient. Blood bank requisition re: reason for transfusion Check order date, time to be given and amount of units Type and cross match complete Baseline set of vital signs: before getting blood only sign out 1 unit of blood at a time, unless emergent situation. WHEN BLOOD COMES ON FLOOR ONLY HAVE 30 MINUTES TO ADMINISTER START after leaving blood bank

febrile, non hemolytic causes and prevention

Most common with multi-transfused recipients. common in cancer patients cause: Leukocyte antibodies in recipient plasma react with donor white cells "Leukocyte depleted" prevention: consider leukocyte poor blood products (filtered, washed, filtered) pretreat with antipyretic if prior history

Blood transfusion reminders

Obtain blood products JUST before you start. If delayed, RETURN to blood bank. Infuse within 4 HOURS to reduce risk of contamination and sepsis. Use large gauge catheter access - #18-20 0.9% NS ONLY Check Compatibility !!! Do not administer any other product or medication with blood tubing.

Benefits of each blood product

RBC: Given to increase the oxygen-carrying capacity of the circulatory system due to acute or chronic blood loss Whole blood: Given to increase the oxygen carrying capacity of the blood and to replace the volume in a patient who is in shock Albumin: Given to replace volume after acute loss, especially in patients who have severe burns and/or who are developing signs of edema; known as a volume expander platelets: Given to prevent and/or control bleeding due to thrombocytopenia Plasma: Given to correct coagulation deficiencies and/or to reverse the effects of warfarin cryoprecipitate: Given to control bleeding by replacing clotting factors

anaphylactic reaction management

Stop infusion Maintain airway/KVO Notify MD/implement orders Administer medication: "CAVE" Epinephrine Antihistamines Corticosteroids Vasopressors Frequent VS Return blood/tubing to lab Test patient for IgA and anti-IgA First occurrence not preventable Do NOT Restart Transfusion!!

6 transfusion Reactions

acute intravascular hemolytic febrile non hemolytic mild allergic (urticaral) anaphylactic circulatory overload sepsis

what to do if blood administration is delayed?

return it back to blood bank

anaphylactic clinical manifestation

Anxiety Urticaria Dyspnea Wheezing (progressing to cyanosis) Hypotension Circulatory Shock Possible cardiac arrest

Which statement is the scientific rationale for infusing a unit of blood in less than 4 hours? 1. The blood will coagulate if left out of the refrigerator for >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 4 hours. 4. The blood will not be affected; this is a laboratory procedure.

Correct 2 1. Blood will coagulate if left out for an extended period of, but blood is stored with a preservative that prevents this and prolongs the life of the blood. 2. (CORRECT). 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 4hours, placing the client at risk for septicemia. 3. Blood components are stable and do not break down after 4hours. 4. These are standard nursing and laboratory procedures to prevent the complication of septicemia.

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 2 months ago. 3. The mother with a 6-week-old newborn. 4. The client who developed an allergy to aspirin in childhood

Correct 3 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 following rubella immunizations for 1month. 3. The client cannot donate blood for 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 that developed during childhood"

pre transfusion assessment

Does the patient know why they are receiving a transfusion? Has the patient ever had a previous transfusion or transfusion reaction? (can make patient very nervous) Explain the procedure to the patient, get to know your patient Review the side effects that they would need to make you aware of immediately if they occur once the transfusion starts: chills, dizziness, fever, low back pain, flushing, tachycardia, tachypnea, hypotension, itching, urticaria (hives), headache, anxiety, muscle pain, wheezing, dyspnea, cough, crackles

The nurse determines that a client is having a transfusion reaction. After the nurse stops the transfusion, which action should immediately be taken next? 1. remove the intravenous 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

Correct 3 If the nurse suspects a transfusion reaction, the nurse stops the transfusion and infuses normal saline at a keep-vein-open rate pending further physician 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 reaction, is suspected. Normal saline is the solution of choice over solutions containing dextrose because saline does not cause red blood cells to clump.

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.

Before starting a transfusion of packed red blood cells for an anemic patient, the nurse would arrange for a peer to monitor his or her other assigned patients for how many minutes when the nurse begins the transfusion? A. 5 minutes B. 15 minutes C. 60 minutes D. 30 minutes

Correct B Patients who are likely to have a transfusion reaction will more often exhibit signs within the first 15 minutes that the blood is infusing

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 client has a hematocrit of 22.3% and a hemoglobin of 7.7 mg/dL. The HCP has ordered 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

Which statement is the scientific rationale for infusing a unit of blood in less than four hours? 1. The blood will coagulate if left out of the refrigerator for longer than four 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 hours. 4. The blood will not be affected; this is a laboratory procedure.

Correct: 2 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 4hours, placing the client at risk for septicemia. 3. Blood components are stable and do not break down at four 4. These are standard nursing and laboratory procedures to prevent the complication of septicemia.

A 28-year old client with cancer is afraid of experiencing a febrile reaction associated with blood transfusions. He asks the nurse if this will happen to him. The nurse's best response is which of the following? 1) Febrile reactions are caused when antibodies on the surface of blood cells in the transfusion are directed against antigens of the recipient. 2) Febrile reactions can usually be prevented by administering antipyretics and antihistamines before the start of the transfusion. 3) Febrile reactions are rarely immune-mediated reactions and can be a sign of hemolytic transfusion. 4) Febrile reactions primarily occur within 15 minutes after initiation of the transfusion and occur during the blood transfusion.

Correct: 2 The administration of antipyretics and antihistamines before initiation of the transfusion in the frequently transfused client can decrease the incidence of febrile reactions. Febrile reactions are immune-mediated and are caused by antibodies in the recipient that are directed against antigens present on the granulocytes, platelets, and lymphocytes in the transfused component. They are the most common transfusion reaction and may occur with onset, during transfusion, or hours after transfusion is completed.

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. Fifteen 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. Which 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. vital sings should be obtained, and the physician notified after treatment is discontinue. The unit in question should not be restarted, and any other units that were issued should not be implemented. 2. just slowing the infusion will not resolve the issue of an allergic reaction to the treatment 3. The symptoms of feeling chilled, being short of breath, and having back pain could 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. Treating the symptoms of the reaction will not resolve the issue of an allergic reaction to the treatment

The nurse and unlicensed nursing assistant are caring for clients on an oncology floor. Which nursing task would be delegated to the unlicensed nursing assistant? 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 teeth.

Correct: 4 1. Unlicensed nursing assistants 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 unlicensed nursing assistant 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 should be given prior to delegating the procedure. (CORRECT) 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 an unlicensed assistant."

The nurse is administering packed red blood cells (PRBCs) to a client. The nurse should first: 1. Discontinue the I.V. catheter if a blood transfusion reaction occurs. 2. Administer the PRBCs through a percutaneously inserted central catheter line with a 20-gauge needle. 3. Flush PRBCs with 5% dextrose and 0.45% normal saline solution. 4. Stay with the client during the first 15 minutes of infusion.

Correct: 4 The most likely time for a blood transfusion reaction to occur is during the first 15 minutes or first 50 mL of the infusion. If a blood transfusion reaction does occur, it is imperative to keep an established I.V. line so that medication can be administered to prevent or treat cardiovascular collapse in case of anaphylaxis. PRBCs should be administered through a 19-gauge or larger needle; a peripherally inserted central catheter line is not recommended, in order to avoid a slow flow. RBCs will hemolyze in dextrose or lactated Ringer's solution and should be infused with only normal saline solution.

A nurse checks a unit of blood received from the blood bank and notes the presence of gas bubbles in the bag. Which should the nurse implement? A. Return the bag to the blood bank. B. Infuse the blood using the filter tubing. C. Add 10ml of NS to the bag. D. Agitate the bag to mix contents gently.

Correct: A The nurse should return the blood to the blood bank because the gas bubbles in the bag indicate possible contamination. If the nurse were going to administer the blood, the nurse would use filter tubing to trap the particulate matter. Although normal saline can be infused concurrently with the blood, NS or any other substance should never be added to the blood in a blood bag. The blood should not be agitated this can harm the RBCs.

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. The gastric analysis was done to determine the primary cause of the anemia. An elevated excretion of the injected radioactive vitamin B12, which is protocol for the first and second stage of the Schilling test, indicates that the client has the intrinsic factor and can absorb vitamin B12 into the intestinal tract. A sedimentation rate of 16 mm/hour is normal for both men and women and is a nonspecific test to detect the presence of inflammation. It is not specific to anemias. An RBC value of 5.0 million is a normal value for both men and women and does not indicate anemia.

Packed red blood cells have been prescribed for a client with a low hemoglobin and hematocrit levels. The nurse takes the client's temperature before hanging the blood transfusion and records 100.6 degrees orally. Which of the following is the appropriate nursing action? A) Begin the transfusion as prescribed B) Delay hanging blood and notify the physician C) Administer an antihistamine and begin the transfusion D) Administer two tablets of Tylenol and begin the transfusion

Correct: B If the client has a temperature higher than 100 degrees, the unit of blood should not be hung until the physician is notified and has the opportunity to give further prescriptions. The physician will likely prescribe that the blood be administered regardless of the temperature, but the decision is not within the nurses's scope of practice to make. The nurse needs a physician's prescription to administer medications to the client. Options A, C, and D can all be excluded as they indicate beginning the transfusion.

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 administration? 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 HIV, human herpesvirus, hepatitis B and C, and cytomegalovirus, 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.

purpose of blood transfusion

Increase circulating blood volume after surgery, trauma, or hemorrhage. Increase the number of RBCs and maintain hemoglobin levels in patient with severe anemia. Provide selected cellular components as replacement therapy. Examples: clotting factors, platelets, and albumin.

sepsis treatment and prevention

Stop infusion/KVO Notify MD/implement medications Antibiotics Treat shock with IV steroids/vasopressors Inspect blood carefully Infuse within designated time. Anticipate: blood cultures Prevention Ensure that Transfusion standards are met. Infused entire unit within 4 hours.

urticarial/ mild allergic management and prevention

Stop transfusion Notify MD Treat symptoms Monitor for laryngeal edema Administer antihistamines as ordered: Diphenhydramine (Benadryl) May restart if symptoms improve Do Not Restart if patient develops fever, pulmonary symptoms, or hypotension. Prevention: Treat prophylactically with antihistamine.

febrile non hemolytic clinical manifestation

Sudden shaking chills (rigors) Fever (Rise in temperature > 1 degree F from baseline. Headache Flushing Muscle pain Itching Urticaria (Hives) Anxiety

Fresh Frozen plasma transfusion therapy

donor Recipent O O A A, O B B, O AB A, B, AB, O