medsurg 2 PRACTICE (mod 1)

The nurse completes all steps of the transfusion reaction protocol for Mr. Bennett. The nurse anticipates that which of the following clinical manifestations related to acute hemolytic transfusion reaction will appear if Mr. Bennett does not respond to medical treatment? (Select all that apply.) - Hypertension - Bronchospasm - Increased urinary output - Bilateral pulmonary infiltrates - Anxiety - Hemoglobinuria

- Bronchospasm - Anxiety - Hemoglobinuria

The nurse recognizes that which of the following steps are essential to complete in the blood transfusion process for Mr. Bennett? (Select all that apply.) - Check unit of blood for gas bubbles and cloudiness. - Double-check the label with another registered nurse. - Ensure administration time does not exceed 2 hours. - Change the blood tubing with each unit. - Instruct the client on signs and symptoms to report immediately. - Assess vital signs.

- Check unit of blood for gas bubbles and cloudiness. - Double-check the label with another registered nurse. - Instruct the client on signs and symptoms to report immediately. - Assess vital signs.

Lloyd Bennett is receiving a blood transfusion for operative blood loss. As part of the process of blood administration, the nurse needs to instruct Mr. Bennett on clinical manifestations to report related to acute hemolytic reaction. The nurse should include which of the following clinical manifestations that are possible in an acute hemolytic reaction? (Select all that apply.) - Hypertension - Dyspnea - Itching - Fever - Chills - Chest tightness

- Dyspnea - Fever - Chills - Chest tightness

The nurse must constantly monitor a client receiving a blood transfusion to ensure that there are no reactions or complications. Which of the following are signs and symptoms of a blood transfusion reaction? (Select all that apply.) - Dyspnea - Low back pain - Fever, chills, or rigors - Hypothermia - Nausea

- Dyspnea - Low back pain - Fever, chills, or rigors - Nausea

Due to Mr. Bennett's age, there is a possibility of a transfusion-associated circulatory overload (TACO). Which of the following client clinical manifestations would represent this particular type of blood transfusion reaction? (Select all that apply.) - Jugular vein distention - Urticaria on the trunk - Severe itching - Crackles in the lungs - Dyspnea - Bronchospasm

- Jugular vein distention - Crackles in the lungs - Dyspnea

In the first few minutes of the blood transfusion, Mr. Bennett says, 'I have back pain, and I don't feel well.' Upon further questioning, he states, 'I feel strange, and my chest hurts.' The nurse suspects that the Mr. Bennett is experiencing a possible transfusion reaction. What steps should the nurse take in a suspected transfusion reaction? (Select all that apply.) - Notify the blood bank regarding the reaction. - Send the blood container and tubing to the blood bank. - Monitor blood pressure for hypertension. - Maintain the IV line with D5W. - Collect a urine sample. - Document the reaction in the client record.

- Notify the blood bank regarding the reaction. - Send the blood container and tubing to the blood bank. - Collect a urine sample. - Document the reaction in the client record.

Which of the following are appropriate interventions to prevent deep vein thrombosis postoperatively in a client who has undergone hip arthroplasty? (Select all that apply.) - Pneumatic compression device - Ankle exercises - Prophylactic anticoagulants - Anti-embolism stockings - Hip flexion (pillow under knee)

- Pneumatic compression device - Anti-embolism stockings - Ankle exercises - Prophylactic anticoagulants

With a suspected blood transfusion reaction, what would the nurse's immediate priorities be? Place the tasks in the order in which the nurse should perform them, from highest priority to least priority. All options must be used. - Notify the blood lab as per hospital policy - Check vital signs - Verify the client ID matches the blood label - Replace tubing containing blood with new tubing primed with NS; do not flush IV tubing containing blood; continue to maintain IV access - Treat symptoms - Notify the provider, but stay with the client - Stop transfusion immediately

1)Stop transfusion immediately 2)Replace tubing containing blood with new tubing primed with NS; do not flush IV tubing containing blood; continue to maintain IV access 3)Check vital signs 4)Notify the provider, but stay with the client 5)Verify the client ID matches the blood label 6)Treat symptoms 7)Notify the blood lab as per hospital policy

The provider has ordered a blood transfusion for the client. The blood transfusion was ordered based on the client's hemoglobin of 7 g/dL. The nurse is aware that the normal hemoglobin for a male client 76 years of age would be which of the following? - 42-52g/dL - 13-18 g/dL - 12-16 g/dL - 35-47g/dL

13-18 g/dL

Which of the following does the nurse know is the most dangerous type of blood transfusion reaction? - Acute hemolytic - Delayed hemolytic - Febrile non-hemolytic - Allergic

Acute hemolytic

In a client experiencing blood loss during surgery, what direction would the nurse expect the postoperative hemoglobin level to change from the preoperative level? - Increase from preoperative level - Decrease from preoperative level - Stay within normal range

Decrease from preoperative level

Which nursing action is appropriate before administering a unit of packed red blood cells? - Use a blood warmer for all transfusions. - Vent the blood container to improve flow. - Educate the client on the signs and symptoms of a blood reaction. - Ensure a small-gauge IV is used to decrease discomfort.

Educate the client on the signs and symptoms of a blood reaction.

Bleeding, hypotension, and oliguria can be associated with which complication? - Hemolytic reactions - Metabolic acidosis - Atelectasis - Non-hemolytic reactions

Hemolytic reactions

Pain, anxiety, hematuria, fever, headache, pruritus, rash or hives, nausea, and respiratory difficulties are common for which negative outcome? - COPD - Plasma - Hemolytic reactions - Non-hemolytic reactions

Non-hemolytic reactions

If a reaction is suspected, the transfusion should be immediately stopped, blood products and tubing removed, and the intravenous line kept open with which of the items listed below? - D5W - Packed red blood cells - Normal saline - Narcan

Normal saline

The nurse recognizes that Mr. Bennett is most likely experiencing a blood transfusion reaction. The nurse's first critical step would be to ____________, and then ___________. . choose answer (1) - start another IV of normal saline - administer oxycodone per provider's orders - discontinue the blood transfusion - administer ondansetron per provider's orders choose answer (2) - reassess vital signs in 30 minutes - notify the provider of client findings - flushes the IV tubing with normal saline - assess client for hypervolemia

discontinue the blood transfusion, notify the provider of client findings