Chapter 31 - Prep U

The nurse should be alert to which adverse assessment finding when transfusing a unit of packed red blood cells (PRBCs) too rapidly?

crackles auscultated bilaterally

Place the following procedural steps in order for transfusing a unit of packed red blood cells (PRBCs).

2-Start an intravenous line. 3-Obtain the unit of PRBCs from the blood bank. 4-Double check the labels with another nurse to ensure 1-Initiate the blood transfusion within 30 minutes of receipt. 5-Monitor closely for signs of a transfusion reaction.

Which client is not a candidate for blood donation according to the American Heart Association? 26 year old female with hemoglobin 11.0 g/dL 86 year old male with blood pressure 110/70 mmHg 50 year old female with pulse 95 beats/minute 18 year old male weighing 52 kg.

26 year old female

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 health care provider may ask for a court order if the client refuses. The client can only refuse the transfusion if the consent form has not been signed. The client has a right to refuse the transfusion. The health care provider may first call the client's parents if the client refuses.

the client has a right to refuse

A nurse is teaching a client with a vitamin B12 deficiency about appropriate food choices to increase the amount of B12 ingested with each meal. The nurse knows the teaching is effective based on which statement by the client? "I will increase my daily intake of orange vegetables such as sweet potatoes and carrots." "I will eat more dairy products such as milk, yogurt, and ice cream every day." "I will eat a spinach salad with lunch and dinner." "I will eat a meat source such as chicken or pork with each meal."

"I will eat a meat source such as chicken or pork with each meal." Vitamin B12 is found only in foods of animal origin.

In normal blood, monocytes account for approximately what percentage of the total leukocyte count? a. 10% b. 209% c. 5% d. 15%

5%

A nursing instructor in a BSN program is preparing for a lecture on disorders of the hematopoietic system. Included in the lecture are conditions caused by reduced levels or absence of blood-clotting proteins. Which of the following is the instructor most likely referring to? a. aplastic anemia b. coagulopathy c. sickle cell disease d. panbcytopenia

B. Coagulopathy a component that is necessary to control bleeding is missing or inadequate

One hour after the completion of a fresh frozen plasma transfusion, a client reports shortness of breath and is very anxious. The client's vital signs are BP 98/60, HR 110, temperature 99.4°F, and SaO2 88%. Auscultation of the lungs reveals posterior coarse crackles to the mid and lower lobes bilaterally. Based on the symptoms, the nurse suspects the client is experiencing which problem? a. delayed hemolytic reaction b. bacterial contamination of blood c. exacerbation of congestive heart failure d. transfusion-related acute lung injury

D. transfusion-related acute lung injury idiosyncratic reatction that is defined as the development of acute lung injury occuring within 6 hours of a blood transfusion more likely to occur when plasma and platelets are transfused. SOB, hypoxia, hypotension, fever, pulmonary edema

The nurse cares for a client with a coagulation factor deficiency who is actively bleeding. Which blood component replacement does the nurse anticipate administering? PRBCs IV gamma-globulin FFP Antithrombin III

FFP

Which term describes the percentage of blood volume that consists of erythrocytes? a. Differentiation b. hematocrit c. erythrocyte sedimentation rate (ESR) d. Hemoglobin

Hematocrit Hematocrit is the percentage of blood volume that consists of erythrocytes

The nurse should provide further teaching about post bone-marrow biopsy procedures when the client makes which statement? "I'll ask someone to drive me home when I awake from general anesthesia." "I should not take aspirin-containing products for pain relief." "I will keep the sterile dressing on until my doctor tells me it's okay to remove it." "I may feel some aching in my hip for 1-2 days."

I'll ask someone to drive me home when I awake from general anesthesia."

A preoperative client is discussing blood donation with the nurse. Which statement by the client indicates to the nurse the need for further teaching? "Donated blood is tested for blood type and infections." "I should expect blood withdrawal to take about 15 minutes." "My family will donate blood, because it's safer." "I could donate my own blood in case I need a transfusion."

My family will donate blood, because it's safer."

The client is diagnosed with polycythemia vera. The nurse prepares the client for which procedure? a. phlebotomy b. platelet infusion c. blood transfusion d. apheresis

Phlebotomy a condition in which the blood contains a large amount of red blood cells, which would increase the viscosity of the blood. phlebotomy is preferred to rid the circulation of excess red blood cells. apheresis is where platelets and leukocyutes are removed from the blood

A nurse, caring for a client with human immunodeficiency virus (HIV), reviews the client's differential WBC count. What type of WBC will the nurse check the level of? B lymphocytes Monocytes Leukocytes T lymphocytes

T cells

A nurse is caring for a client with a diagnosis of lymphocytopenia. Which assessment finding will the nurse consider most concerning when caring for this client? a. BP 132/92' b. INR 0.9 c. prothrombin time 12 seconds d. temperature of 37.7 degrees celsius

Temperature of 37.7 degrees celsius lymphocytopenia is a decrease in the number of lymphocytes and they fight foreign and infectious organisms. 37.7 celsius converts to 99.9 fahrenheit and may be indicative of a low grade fever/infection

The nurse is caring for a client with hypoxia. What does the nurse understand is true regarding the client's oxygen level and the production of red blood cells? The bone marrow is stimulated by low oxygen levels in the blood and stimulates erythropoietin, maturing the red blood cells. The brain senses low oxygen levels in the blood and stimulates hemoglobin, which binds to more red blood cells. The kidneys sense low oxygen levels in the blood and stimulate hemoglobin, stimulating the marrow to produce more red blood cells. The kidneys sense low oxygen levels in the blood and stimulate erythropoietin, stimulating the marrow to produce more red blood cells.

The kidneys sense low oxygen levels in the blood and stimulate erythropoietin, stimulating the marrow to produce more red blood cells.

A client with Hodgkin disease had a bone marrow biopsy yesterday and reports aching at the biopsy site, rated a 5 (on a 1-10 scale). After assessing the biopsy site, which nursing intervention is most appropriate? a. Administer acetaminophen 500 mg po, as ordered b. Administer aspirin (ASA) 325 mg po, as ordered c. Notify the physician d. Reposition the client to a high Fowler position and continue to monitor the pain

a. administer acetaminophen 500 mg po apply pressure for several minutes and then cover with a sterile dressing. aspirin containing analgesic agents should be avoided in the immediate post-procedure period because they can aggravate or potentiate bleeding

During a blood transfusion with packed red blood cells (RBCs), a client reports chills, low back pain, and nausea. What priority action should the nurse take? a. discontinue the infusion immediately and maintain the IV line with normal saline solution using the new IV tubing b. slow the infusion rate and continue to monitor the client every 15 minutes c. discontinue the infusion immediately and notify the physician d. observe for additional symptoms ad notify the physician

a. discontinue the infusion immediately and maintain the IV line with normal saline solution using the new IV tubing Suspected transfusion reaction has occurred - send the blood container and the tubing to the blood bank for repeat typing and culture but stop the transfusion and maintain the IV line with NS through new tubing. assess pt and notify the physician.

A nurse cares for a client with megaloblastic anemia who had a total gastrectomy three years ago. What statement will the nurse include in the client's teaching regarding the condition? a. "The condition is likely caused by a vitamin B12 deficiency." b. "The condition causes abnormally rigid red blood cells." c. "The condition is likely caused by a folate deficiency." d. "The condition causes abnormally small red blood cells."

a. the condition is likely caused by a vitamin b12 deficiency

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.) Continue the infusion but slow the rate down. Discontinue the transfusion. Administer diuretics as prescribed. Place the patient in an upright position with the feet dependent. Administer oxygen.

administer diuretics as prescribed discontinue the transfusion administer oxygen place the patient in an upright position with the feet dependent

The nurse is obtaining the health history of a client suspected of having a hematological condition. The nurse notes the client has a history of alcohol abuse. Which clinical presentation is related to alcohol consumption? Neutropenia Myelodysplastic syndrome Anemia Thrombocytopenia

anemia

The physician performs a bone marrow biopsy from the posterior iliac crest on a client with pancytopenia. What intervention should the nurse perform after the procedure? Apply pressure over the site for 5-7 minutes Elevate the head of the bed to 45 degrees Pack the wound with half-inch sterile gauze Administer a topical analgesic to control pain at the site

apply pressure over the site for 5-7 minutes

G-CSF (filgrastim) is prescribed for a client with bone marrow suppression. What medication administration teaching should the nurse provide to the client? Do not eat before arriving to receive the intravenous administration of filgrastim. Filgrastim is taken intramuscularly on a weekly basis. Take this medication by mouth at bedtime each night. Assist the client in identifying appropriate subcutaneous injection sites.

assist the clinet in identifuying approoriate sub q injection sites bc neupogen is taken sub q

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? a. filgrastim b. epoetin alfa c. eltrombopag d. sargramostim

b. epoetin alfa

A nurse is reviewing a client's morning laboratory results and notes a left shift in the band cells. Based on this result, the nurse can interpret that the client A. may be developing anemia b. may be developing a infection' c. has leukopenia d. has thrombocytopenia

b. may be developing an infection

One hour after a transfusion of packed red blood cells (RBCs) is started, a client develops redness on the trunk and reports itching. The nurse stops the RBC infusion and administers diphenhydramine 25 mg po, as ordered. Thirty minutes later, the redness and itching are gone. What action should the nurse take next? a. Position the client in an upright position with the feet in a dependent position b. Send the blood back to the blood bank c. Resume the transfusion d. Obtain blood and urine samples from the client

b. resume the transfusion some patients develop urticaria or generalized itching during a transfusion and may be due to a sensitivity reaction to a plasma protein. usually mild reactions that resolve after admin of an antihistamine

A nurse practitioner reviewed the blood work of a male client suspected of having microcytic anemia. The nurse suspected occult bleeding. Which laboratory result would indicate an initial stage of iron deficiency? a. serum iron: 100g/dl b. serum ferritin: 15ng/ml c. total iron-binding capacity: 300g/dl d. hemoglobin: 16 g/dl

b. serum ferritin: 15 ng/mL microcytic anemia is characterized by small RBC's due to insufficient hemoglobin. serum ferritin levels correlate to iron deficiency and decrease as an initial response to anemia before hemoglobin and serum iron levels drop

The nurse recognizes that the most common cause of iron deficiency anemia in an adult is lack of dietary iron. bleeding. iron malabsorption. chronic alcoholism.

bleeding

The charge nurse should intervene when observing a new nurse perform which action after a client has suffered a possible hemolytic blood transfusion reaction? a. Informing the client to leave a urine sample after the client's next void. b. Documenting the reaction in the client's medical record. c. Notifying the blood bank of the reaction. d. Disposing of the blood container and tubing in biohazard waste.

c. disposing of the blood container and tubing in biohazard waste the blood container and tubing should be returned to the blood bank for repeat typing and culture and the blood bank should be notified of the reaction. urine ASAP to detect hemoglobin in urine

Which is the major function of neutrophils? a. destruction of tumor cells b. rejection of foreign tissue c. phagocytosis d. production of immunoglobulins

c. phagocytosis t cells= rejection of foreign tissue and destruction of tumor cells plasma cells - immunoglobulins

The nurse is instructing the client with polycythemia vera how to perform isometric exercises such as contracting and relaxing the quadriceps and gluteal muscle during periods of inactivity. What does the nurse understand is the rationale for this type of exercise? Contraction of skeletal muscle compresses the walls of veins and increases the circulation of venous blood as it returns to the heart. This type of exercise increases arterial circulation as it returns to the heart. Isometric exercise decreases the workload of the heart and restores oxygenated blood flow. Isometric exercise programs are inclusive of all muscle groups and have an aerobic effect to increase the heart rate.

contraction of skeletal myuscle compresses the walls of veins and increase the circulation of venous blood as it returns to the heart

Which of the following cells are capable of differentiating into plasma cells? a. neutrophils b. eosinophils c. T lymphocytes d. B lymphocytes

d. B lymphocytes B lymphocytes are capable of differentiating into plasma cells. plasma cells in turn produce antibodies called immunoglobulins which are protein molecules that destroy foreign materia by several mechanisms

An older adult client presents to the health care provider's office and reports exhaustion. The nurse, aware of the most common hematologic condition affecting the elderly, knows that which laboratory values should be assessed? a. WBC count b. level of plasma proteins c. thrombocyte count d. RBC count

d. RBC count

A client who has idiopathic thrombocytopenia purpura (ITP) has a critically low platelet count. Which nursing intervention will be included in the care plan for this client? a. adminster epoetin alfa b. enforce strict contact isolation c. place the client in a private room d. administer eltrombopag

d. adminster eltrombopag

A client is receiving platelets. In order to decreased the risk of circulatory overload in this client, what action should the nurse take? a. administer each unity slowly over 3-4 hours b. flush the intravenous line with a liter of saline between units c. monitor vital signs closely before transfusion and once per shift d. infuse each unit over 30-60 minutes per client tolerance

d. infuse each unit over 30-60 minutes per client tolerance infuse each unit of FFP 30-60 mn because platelet clumping with occur if administered too slowly. vitals should be monitored before and during transfusion. 1L of saline is too large and would cause FVE

Which nursing intervention should be incorporated into the plan of care for a client with impaired liver function and a low albumin concentration? a. monitor temperature at least once per shift b. implement neutropenic precautions c. apply prolonged pressure to needle sites or other sources of external bleeding d. monitor edema at least once per shift

d. monitor edema at least once per shift albumin is important for the maintenance of fluid balance within the vascular system

A client involved in a motor vehicle accident arrives at the emergency department unconscious and severely hypotensive. The nurse suspects the client has several fractures in the pelvis and legs. Which parenteral fluid is the best choice for the client's current condition? a. normal saline solution b. lactated ringers solution c. fresh frozen plasma d. packed red blood cells

d. packed red blood cells in a trauma situation the first blood product given is unmatched o-negatived packed rbcs, fresh frozen is commonly used to replace clotting factors ns/lr is used to increase bp and volume byt too much colloid will hemodilute the blood and wont increase oxygen carrying capacity

A nursing instructor is reviewing the role and function of stem cells in the bone marrow with a group of nursing students. After providing the explanation, the instructor asks the students to use their knowledge of anatomy and physiology to determine an alternate way in which adults with diseases that destroy marrow can resume production of blood cells. Which explanation by the students is correct? a. The remaining stem cells have the ability to continue with the process of self-replication, creating an endless supply. b. Fat found in yellow bone marrow can be replaced by active marrow when more blood cell production is required. c. The three cell types—erythrocytes, leukocytes, and platelets—can resume production of stem cells. d. The liver and spleen can resume production of blood cells through extramedullary haematopoiesis.

d. the liver and spleen can resume production of blood cells through extramedullary haematopoiesis in adults with disease that destroy marrow or cause fibrosis or scarring, the liver and spleen can also resume production of blood cells

The physician orders a transfusion with packed red blood cells (RBCs) for a client hospitalized with severe iron deficiency anemia. When blood is administered, what is the most important action the nurse can take to prevent a transfusion reaction? a. assess the client 30 minutes after the start of the initial transfusion b. administer the blood as soon as it arrives c. premedicate the client with acetaminophen d. verify the clients identity according to the hospital policy

d. verify the clients identify according to the hospital policy

A nurse cares for an older adult client with acute myeloid leukemia (AML). What concept does the nurse understand leads to the increased risk of an older adult acquiring myeloid malignancies such as AML?

damage to stem

Post transfusion, the donor stands up immediately after the needle is withdrawn. The nurse should be alert for which vital sign change? Elevated temperature. Decreased blood pressure. Decreased respiratory rate. Decreased pulse.

decreased blood pressure

A patient with chronic kidney disease is being examined by the nurse practitioner for anemia. The nurse has reviewed the laboratory data for hemoglobin and RBC count. What other test results would the nurse anticipate observing? Decreased level of erythropoietin Increased reticulocyte count Decreased total iron-binding capacity Increased mean corpuscular volume

decreased level of erythropoiuetin

When conducting a health assessment on a client suspected for having a hematological disorder, the nurse should collect which data? Select all that apply. dietary intake ethnicity hair color herbal supplements medication use

dietary intake herbal supplements medication use

A client receiving a unit of packed red blood cells (PRBCs) has been prescribed morphine 1 mg intravenously now for pain. What is the best method for the nurse to administer the morphine? Inject the morphine into a distal port on the blood tubing. Add the morphine to the blood to be slowly administered. Administer the morphine into the closest tubing port to the client for fast delivery. Disconnect the blood tubing, flush with normal saline, and administer morphine.

disconnect the blood tubing. flush with normal salione, and administer morphine

A patient is undergoing platelet pheresis at the outpatient clinic. What does the nurse know is the most likely clinical disorder the patient is being treated for? Renal transplantation Sickle cell anemia Extreme leukocytosis Essential thrombocythemia

essential thrombocythemia used to remove platelets int he blood in patients with extreme thrombocytosis or essential thrombocythemia or in a single-donor platelet transfusion

A nurse is completing a detailed health history and assessment in the electronic medical record (EMR) for a client with a disorder of the hematopoietic system. Which symptom is the most commonly reported in association with hematologic diseases? Severe headaches Blurred vision Extreme fatigue Dyspnea

extreme fatigue

A nurse is caring for a client who has been diagnosed with an autosomal dominant hematologic disorder. Which disease does the nurse suspect? Hemochromatosis Factor V Leiden Thalassemia Sickle cell disease

factor V leiden

The nurse caring for a client with acute liver failure should expect which assessment finding? Elevated blood pressure Elevated albumin level Generalized edema Decreased pulse

generalized edema

A nurse administers blood products to a client with Hodgkin disease. During the administration, the nurse notes the client has a fever and diffuse reddened skin rash. From what condition does the nurse suspect the client is suffering?

graft versus host

A nurse is performing an initial assessment and notes the client's skin is a gray-tan color, especially on the scars of the client's arms. Which hematological condition does the nurse suspect? Hemochromatosis Vitamin B12 deficiency Thrombocytopenia Polycythemia

hemochromatosis

A nurse is caring for a patient who has had a bone marrow aspiration with biopsy. What complication should the nurse be aware of and monitor the patient for? Splintering of bone fragments Hemorrhage Shock Blood transfusion reaction

hemorrhage

After withdrawing the needle from blood donor's arm, the site begins to bleed excessively. What is the nurse's first action? Apply a tourniquet above the antecubital fossa. Assist the client into an erect position. Hold firm pressure on the venipuncture site. Lower the arm below the level of the heart.

hold firm pressure on the venipuncture site

Splenic sequestration is diagnosed in a client admitted with splenomegaly. What is the priority of care for this client? Hypovolemia Hyperthermia Hypertension Infection

hypovolemia

A nurse cares for a client with myelodysplastic syndrome who requires frequent PRBC transfusions. What blood component does the nurse recognize as being most harmful if accumulated in the tissues due to chronic blood transfusions?

iron

The client's CBC with differential reveals small-shaped hemoglobin molecules. The nurse expects to administer which medication to this client? Folate Vitamin B12 Fresh frozen plasma Iron

iron

The client's CBC with differential reveals small-shaped hemoglobin molecules. The nurse expects to administer which medication to this client? Fresh frozen plasma Folate Iron Vitamin B12

iron With iron deficiency, the erythrocytes produced by the marrow are small and low in hemoglobin. Vitamin B12 and folate deficiencies are characterized by the production of abnormally large erythrocytes. Fresh frozen plasma are infused due to a low platelet level, not light-colored hemoglobin.

The nurse is providing health education to an older adult client who has low red blood cell levels. To promote red blood cell production, the nurse should encourage intake of what foods? Select all that apply. a. lean meats b. organic foods c. nuts and seeds d. leafy green vegetables e. animal fats

leafy green vegetables lean meats nuts and seeds

What food should the nurse recommend for a client diagnosed with vitamin B12 deficiency? Green vegetables Citrus fruit Whole-grain bread Lean meat

lean meat

Vitamin B and folic acid deficiencies are characterized by production of abnormally large erythrocytes called mast cells. blast cells. monocytes. megaloblasts.

megaloblasts

A nurse working in hematology reviews the characteristics of stem cells and their role in disease. Which statements does the nurse understand is true regarding stem cells? Select all that apply. there is a limited supply throughout the life cycle. Myeloid stem cells produce erythrocytes. They have the ability to self-replicate. Lymphoid stem cells produce lymphocytes. There is a continuous supply throughout the life cycle.

myeloid stem cells produce erythrocytes they have the ability to self-replicate lymphoid stem cells produce lymohocytes there is a continuous supply throughout the life cycle

The body responds to infection by increasing the production of white blood cells (WBCs). The nurse should evaluate the differential count for what type of WBCs, which are the first WBCs to respond to an inflammatory event? Basophils Monocytes Neutrophils Eosinophils

neutrophils

The nurse is completing a pretransfusion assessment to determine a female client's history of previous transfusions as well as previous reactions to transfusions. Which is the most important information to obtain from this client before the transfusion?

number of pregnancies

A patient receiving plasma develops transfusion-related acute lung injury (TRALI) 4 hours after the transfusion. What type of aggressive therapy does the nurse anticipate the patient will receive to prevent death from the injury? (Select all that apply.) Fluid support Oxygen Intubation and mechanical ventilation Serial chest x-rays Intra-aortic balloon pump

oxygen fluid support intubation and mechanical ventilation

A nurse cares for a client who has had a bone marrow aspiration. In addition to the client's aspiration site, what locations on the body does the nurse recognize as having bone marrow? Select all that apply. a. ribs b. sternum c. tibia d. pelvis e. vertebrae

pelvis, ribs, vertebrae, sternum the tibia does not have bone marrow

The nurse reviewing laboratory results of a client recovering from abdominal surgery notices an elevated number of reticulocytes. What is the nurse's first action? Notify the healthcare provider. Hold the prescribed blood transfusion. Perform an abdominal assessment. Document the findings as expected results.

perform an abdominal assessment

The client is planned to have a splenectomy. The nurse should prepare which medication to administer to this client? Pneumococcal vaccine Aspirin Factor VIII Immunoglobulin G (IgG)

pneumococcal vaccine

The nurse is completing a physical assessment on a client's lymphatic system. The nurse should palpate for enlarged nodes in which areas? Select all that apply. Popliteal Spinal Submental Inguinal Neck

popliteal submental inguinal neck

When teaching about the advantages of autologous blood transfusion to a client, the nurse should include which information? Select all that apply. Blood can be transfused to family members and close relatives. If not needed immediately, the blood can be frozen for future use. The primary advantage is prevention of viral infections. It is safer for clients with a history of transfusion reactions. It resolves anemia for clients with a hemoglobin less than 11g/dL.

prevention of viral infections safer for clients with a hisotyr of transfusion reactions if not needed immediately, the blood can be frozen for future use

A nurse is assisting a client into position prior to bone marrow aspiration. Which position will the nurse place the client prior to the procedure? Prone Trendelenberg Knee-chest Supine

prone

Place the clotting cascade in the correct order.

prothrombin activator prothrombin thrombin fibrinogen fibrin

A client reports feeling faint after donating blood. What is the nurse's best action? Assist the client into high-Fowler's position. Place the client in Trendelenburg position. Ambulate client with assistance. Keep client in recumbent position to rest.

recumbent positikon

A nurse cares for several mothers and babies in the postpartum unit. Which mother does the nurse recognize as being most at risk for a febrile nonhemolytic reaction? Rh-positive mother; Rh-negative child Rh-positive mother; Rh-positive child Rh-negative mother; Rh-positive child Rh-negative mother; Rh-negative child

rh neg mom and rh pos baby

The nurse expects which assessment finding of the oral cavity when the client is diagnosed with pernicious anemia? Enlarged gums Angular cheilosis Smooth tongue Ulcerations of oral mucosa

smooth tongue

The nurse began transfusing the first unit of packed red blood cells (PRBCs) fifteen minutes ago. The client reports shortness of breath, nausea, and is restless. What is the nurse's priority action? Flush the blood tubing with normal saline. Notify the primary health care provider. Discontinue the intravenous line. Stop the infusion.

stop the infusion

The nurse is administering a blood transfusion to a client over 4 hours. After 2 hours, the client reports chills and has a fever of 101°F, an increase from a previous temperature of 99.2°F. What does the nurse recognize is occurring with this client? The client is having a febrile nonhemolytic reaction. The client is having decrease in tissue perfusion from a shock state. The client is experiencing vascular collapse. The client is having an allergic reaction to the blood.

the client is having a febrile nonhemolytic reaction

When administering a blood transfusion to a client with multiple traumatic injuries, the nurse monitors closely for evidence of a transfusion reaction. Shortly after the transfusion begins, the client complains of chest pain, nausea, and itching. When urticaria, tachycardia, and hypotension develop, the nurse stops the transfusion and notifies the physician. The nurse suspects which type of hypersensitivity reaction? Type I (immediate, anaphylactic) hypersensitivity reaction Type II (cytolytic, cytotoxic) hypersensitivity reaction Type IV (cell-mediated, delayed) hypersensitivity reaction Type III (immune complex) hypersensitivity reaction

type 2 cytoltic cytotoxic hypersensitivity reaction

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 develops a hemolytic reaction to a blood transfusion. What actions should the nurse take after this occurs? Select all that apply. Document the reaction according to policy Administer diphenhydramine Begin iron chelation therapy Collect a urine sample to detect hemoglobin Obtain appropriate blood specimens

urine sample document reaction according to policy obtain appropriate blood specimens

While caring for a client, the nurse notes petechiae on the client's trunk and lower extremities. What precaution will the nurse take when caring for this client? Apply supplemental oxygen to maintain the client's oxygenation. Use an electric razor when assisting client with shaving. Elevate the client's head of the bed. Where a mask when entering the client's room.

use an electric razor when shaving