Blood Transfusion 420 practice
A client has an order to receive a one unit of packed RBC's. The nurse make sure which of the following intravenous solutions to hang with the blood product at the client's bedside?
0.9% sodium chloride. RAtionale: 0.9% sodium chloride is a standard solution used to follow infusion of blood products. Options B, C, and D: IV solution containing dextrose in water will hemolyze red cells.
A client is receiving a first-time blood transfusion of packed RBC. How long should the nurse stay and monitor the client to ensure a transfusion reaction will not happen?
15 minutes Rationale: Usually, a transfusion reaction occurs within the 15 minutes of a transfusion.
When to assess
Assess vitals before, during, and after transfusion.
Cross match blood transfusion
Crossmatching is a way for your healthcare provider to test your blood against a donor's blood to make sure they are fully compatible. Crossmatching takes 45 minutes to an hour. It's essentially a trial transfusion done in test tubes to see exactly how your blood will react with potential donor blood.
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 100.8 °F. Which action should the nurse take?
Delay hanging the blood and inform the physician. Rationale: f the client has a temperature higher than 100 ° F, the unit of blood should be hung and delayed until the physician is notified and has the opportunity to give further order. Options A and C are incorrect since the administration of the medicine will need the physician's prescription. Option B: The decision to administer the blood is not within the scope of nurse practice.
Reactions to Blood Transfusions
Fever, chills, itching, Hives (urticaria), anaphylaxis, chest pain, hypotension
Which nursing intervention takes highest priority when caring for a newly admitted client who's receiving a blood transfusion?
Instructing the client to report any itching, chest pain, or dyspnea. Rationale: This will help the nurse take immediate action incase a reaction happens during a transfusion.
A client is brought to the emergency department having experienced blood loss due to a deep puncture wound. A 3 unit Fresh-frozen plasma (FFP) is ordered. The nurse determines that the reason behind this order is to:
Provide clotting factors and volume expansion Rationale: Fresh-frozen plasma may be used to provide clotting factors or volume expansion. It is rich in clotting factors and can be thawed quickly and transfused right away. Option B is incorrect since it will not specifically increase the hemoglobin, hematocrit, and neutrophil level. Options C and D are incorrect since FFP does not contain any platelet.
After terminating the transfusion during a reaction, which action should the nurse immediately be taken next?
Run normal saline at a keep-vein-open rate Rationale: The nurse will infuse normal saline at a KVO rate to keep the patency of the IV line while waiting for further orders from the physician. Option A: IV solution containing dextrose will hemolyze the red cells. Option C: The nurse will not remove the IV line because then there would be no IV access route. Option D: Doing a fast drip will potentially lead to congestion and is not done without the physician order
Transfusion Associated Circulatory Overload (TACO)
Volume overload temporally associated with transfusion. S/S: SOB, increase RR, hypoxemia, Increased left atrial pressure, JVD, Elevated systolic pressure. Treatment: Oxygen, possible intubation/ mechanical ventilation, Diuresis to reduce volume. Also consider MI
Blood typing
negative blood type (O-) can give to positive but you cannot give positive blood to negative blood.
When to redraw labs?
redraw labs in between units of blood transfused. Typically within 1 hour.
Nurse Jay is caring for a client with an ongoing transfusion of packed RBC's when suddenly the client is having difficulty of breathing, skin is flushed and having chills. Which action should nurse jay take first?
Stop the transfusion!! Rationle: The client in this situation is experiencing transfusion reaction so the priority action of the nurse is to first stop the transfusion.
A client is receiving transfusion of one unit of cryoprecipitate. The nurse will review which of the following laboratory studies to assess the effectiveness of the therapy?
Coagulation studies. Rationale: The evaluation of an effective response of a cryoprecipitate transfusion is assessed by monitoring coagulation studies and fibrinogen levels. Options A, C, and D are reviewed after transfusion of packed reb blood cells.
A nurse is caring for a client requiring surgery and is ordered to have a standby blood secured if in case a blood transfusion is needed during or after the procedure. The nurse suggest to the client to do which of the following to lessen the risk of possible transfusion reaction?
Do an autologous blood donation. Rationale: A donation of the own blood is autologous. Doing this will prevent the risk of transfusion reaction.
Nurse Paulo has received a blood unit from the blood bank and has rechecked the blood bag properly with nurse Edward. Prior the facilitation of the blood transfusion, nurse Paulo priority check which of the following?
Vital signs Rationale: The nurse must assess the vital signs before and 15 minutes after the procedure so that any changes during the transfusion may indicate a transfusion reaction is happening.
hemoglobin and hematocrit lab levels ( left to right)
Women 12:36 Men 13:39
To verify the age of blood cells in a blood, the nurse will check which of the following?
Blood expiration date Rationale: The safe storage of blood usually takes 35 days. Examining the expiration date is an important responsibility of a nurse prior hanging the blood.
Nurse Amanda is caring for a client with severe blood loss who is prescribed with multiple transfusion of blood. Nurse Amanda obtains which most essential piece of equipment to prevent the risk of cardiac dysrhythmias?
Blood warmer. Rationale: Rapid transfusion of cool blood put the client at risk for cardiac dysrhythmias. Options A and C are used to assess for any blood transfusion-related complication but they do not prevent the occurrence of cardiac dysrhythmia. Option D is not beneficial in this case since the infusion must be given rapidly.
Transfusion Related Acute Lung Injury (TRALI)
Leading cause of transfusion related mortality. Leakage of fluid into alveolar space due to diffuse alveolar capillary damage. S/S: SOB, increase RR, Hypoxemia, hypotension, occasional fever. Treatment: Oxygen, possible intubation & mechanical ventilation, possible fluids to treat hypotension.
A client is receiving a platelet transfusion. The nurse determines that the client is gaining from this therapy if the client exhibits which of the following?
Less episodes of bleeding Rationale: Platelet transfusions may be given to prevent bleeding when the platelet count falls down. Option A: A decline in the febrile episode will happen after the transfusion of agranulocytes. Options B and D: An increased level of hemoglobin and hematocrit will happen after the transfusion of red blood cells.
Nurse Daniel is caring for a client receiving a transfusion of packed red blood cells (PRBCs). The client started to vomit and to be nauseous. Client's blood pressure is 95/40 mm Hg from a baseline of 110/70 mm Hg. The client's temperature is 100.5°F orally from a baseline of 99.5°F orally. The nurse understand that the client may be experiencing which of the following?
Septicemia Rationale: Septicemia happens with the transfusion of blood that is contaminated with microorganisms. Assessment includes rapid onset of high fever and chills, hypotension, nausea, diarrhea, vomiting, and shock. Option A: Circulatory overload causes hypertension, cough, dyspnea, chest pain, tachycardia, and wheezing upon auscultation. Option B: Delayed reaction can occur days to years after a transfusion. It causes, fever, rashes, mild jaundice, and oliguria or anuria. Option C: Hypocalcemia causes paresthesias, tetany, muscle cramps, hyperactive reflexes, positive Trousseau's sign, and positive Chovstek's sign.
Nurse Rick is administering a 2 unit packed RBC's on a client with a low hemoglobin. The nurse will prepare which of the following in order to transfuse the blood?
Tubing with an in-line filter Rationale: The in-line filter helps ensure that any particles larger than the size of the filter are caught in the filter and are not infused with the client. Option A is incorrect since the tubing that should be used is a macro drip. Option B is used for administration of IV medication infusion. Option C is incorrect since blood does not need any protection from light.
When to transfuse?
When Hgb is below 7 or they are symptomatic
autonomous
Your own blood draw and can be readmitted to you if needed (ex. scheduled surgery)