Transfusions

A nurse has participated in organizing a blood donation drive at a local community center. Which of the following individuals would most likely be disallowed from donating blood?

A woman whose blood pressure is 88/51 mm Hg

A client tells the nurse that he would like to donate blood before his abdominal surgery next week. What should be the nurse's first action?

Explain the time frame needed for autologous donation.

The nurse is administering 2 units of packed RBCs to an older adult patient who has a bleeding duodenal ulcer. The patient begins to experience difficulty breathing and the nurse assesses crackles in the lung bases, jugular vein distention, and an increase in blood pressure. What action by the nurse is necessary if the reaction is severe? (Select all that apply.)

Place the patient in an upright position with the feet dependent. Administer diuretics as prescribed. Discontinue the transfusion. Administer oxygen.

When teaching about the advantages of autologous blood transfusion to a client, the nurse should include which information? Select all that apply.

The primary advantage is prevention of viral infections. It is safer for clients with a history of transfusion reactions. If not needed immediately, the blood can be frozen for future use.

Albumin is important for the maintenance of fluid balance within the vascular system. Albumin is produced by which of the following?

liver

Which is a symptom of severe thrombocytopenia?

petechiae

A client is in the hospital with a bleeding gastric ulcer and requires a blood transfusion. He has been typed and crossmatched for 2 units of packed red blood cells and found to have type O blood. What type of blood will the nurse administer to this client?

type O

A client verbalizes fear of infection from a blood transfusion. What is the nurse's best response?

"Every unit of donated blood is typed and tested for antibodies to infections."

The nurse began transfusing the first unit of packed red blood cells (PRBCs) fifteen minutes ago. The client begins complaining of shortness of breath, nausea, and is restless. What is the nurse's priority action?

stop the transfusion

Post transfusion, the donor stands up immediately after the needle is withdrawn. The nurse should be alert for which vital sign change?

decreased blood pressure

The nurse expects which assessment finding when caring for a client with a decreased hemoglobin level?

decreased oxygen level

The nurse should notify the healthcare provider before administering fresh frozen plasma (FFP) based on which assessment finding?

jugular venous distension

A nurse reviews a client's laboratory results and notes the client has a decreased lymphocyte count. What nursing diagnosis will the nurse use when planning the client's care?

risk for infection

A 18-year-old client presents to the emergency department with a severe open fracture of the lower extremity. The health care provider tells the client that the client will need a blood transfusion. The client refuses, despite the advise of the health care provider. What does the nurse understand is the legal implication of the scenario?

the client has a right to refuse the transfusion

The client is to receive a unit of packed red blood cells. The first intervention of the nurse is to

verify that the client has signed a written consent form

A patient develops a hemolytic reaction to a blood transfusion. What actions should the nurse take after this occurs? (Select all that apply.)

Obtain appropriate blood specimens. Collect a urine sample to detect hemoglobin. Document the reaction according to policy.

A client involved in a motor vehicle accident arrives at the emergency department unconscious and severely hypotensive. The nurse suspects he has several fractures in the pelvis and legs. Which parenteral fluid is the best choice for the client's current condition?

Packed red blood cells (RBCs)

A client on the medical unit is receiving a unit of PRBCs. Difficult IV access has necessitated a slow infusion rate and the nurse notes that the infusion began 4 hours ago. What is the nurse's most appropriate action?

Discontinue the remainder of the PRBC transfusion and inform the health care provider.

A client with severe anemia is admitted to the hospital. Because of religious beliefs, the client is refusing blood transfusions. The nurse anticipates pharmacologic therapy with which drug to stimulate the production of red blood cells?

epoetin alfa

A patient with chronic kidney disease has chronic anemia. What pharmacologic alternative to blood transfusion may be used for this patient?

erythropoietin (epogen)