NCLEX - Blood Administration

117. The 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 question? 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?"

1. "Have you ever had a transfusion before?" Asking the client about personal experience with transfusion therapy provides a good starting point for client teaching about this procedure. Options 3 and 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.

123. The nurse has just received a prescription to transfuse a unit of packed red blood cells for an assigned client. Approximately how long will the nurse need to stay with the client to ensure that a transfusion reaction is not occurring? 1. 5 minutes 2. 15 minutes 3. 30 minutes 4. 45 minutes

2. 15 minutes The nurse must remain with the client for the first 15 minutes of a transfusion, which is usually when a transfusion reaction may occur. This enables the nurse to detect a reaction and intervene quickly. The nurse engages in safe nursing practice by obtaining coverage for the other assigned clients during this time. Therefore options 1, 3, and 4 are incorrect time frames.

127. The nurse who is about to begin 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? 1. Expiration date 2. Presence of clots 3. Blood group and type 4. Blood identification number

1. Expiration date The nurse notes the expiration date on the unit of blood to ensure that the blood is fresh. Blood cells begin to deteriorate over time, so safe storage usually is limited to 35 days. Careful notation of the expiration date by the nurse is an essential part of the verification process before hanging a unit of blood. The nurse also notes the blood identification (unit) number, blood group and type, and client's name. The nurse also inspects the unit of blood for leaks, abnormal color, clots, and bubbles and returns the unit to the blood bank if clots are noted.

128. A client requiring surgery is anxious about the possible need for a blood transfusion during or after the procedure. The nurse suggests to the client to do which of the following to reduce the risk of possible transfusion complications? 1. Give an autologous blood donation before the surgery. 2. Ask a friend or family member to donate blood ahead of time. 3. Take iron supplements before surgery to boost hemoglobin levels. 4. Request that any donated blood be screened twice by the blood bank.

1. Give an autologous blood donation before the surgery. A donation of the client's own blood before a scheduled procedure is autologous. Donating autologous blood to be reinfused as needed during or after surgery reduces the risk of disease transmission and potential transfusion complications. The next most effective way is to ask a family member to donate blood before surgery. Blood banks do not provide extra screening on request. Preoperative iron supplements are helpful for iron deficiency anemia but are not helpful in replacing blood lost during the surgery.

118. A client receiving a transfusion of packed red blood cells (PRBCs) begins to vomit. The client's blood pressure is 90/50 mm Hg from a baseline of 125/78 mm Hg. The client's temperature is 37.5 orally from a baseline of 38.8 F orally. The nurse determines that the client may be experiencing which complication of a blood transfusion? 1. Septicemia 2. Hyperkalemia 3. Circulatory overload 4. Delayed transfusion reaction

1. Septicemia Septicemia occurs with the transfusion of blood contaminated with microorganisms. Signs include chills, fever, vomiting, diarrhea, hypotension, and the development of shock. Hyperkalemia causes weakness, paresthesias, abdominal cramps, diarrhea, and dysrhythmias. Circulatory overload causes cough, dyspnea, chest pain, wheezing, tachycardia, and hypertension. A delayed transfusion reaction can occur days to years after a transfusion. Signs include fever, mild jaundice, and a decreased hematocrit level.

122. The nurse has obtained a unit of blood from the blood bank and has checked the blood bag properly with another nurse. Just before beginning the transfusion, the nurse assesses which priority item? 1. Vital signs 2. Skin color 3. Urine output 4. Latest hematocrit level

1. Vital signs A change in vital signs during the transfusion from baseline may indicate that a transfusion reaction is occurring. This is why the nurse assesses vital signs before the procedure and again after the first 15 minutes. The other options do not identify assessments that are a priority just before beginning a transfusion.

124. A client has a prescription to receive a unit of packed red blood cells. The nurse should obtain which of the following intravenous (IV) solutions from the IV storage area to hang with the blood product at the client's bedside? 1. Lactated Ringer's 2. 0.9% sodium chloride 3. 5% dextrose in 0.9% sodium chloride 4. 5% dextrose in 0.45% sodium chloride

2. 0.9% sodium chloride Sodium chloride 0.9% (normal saline) is a standard isotonic solution used to precede and follow infusion of blood products. Dextrose is not used because it could result in clumping and subsequent hemolysis of red blood cells. Lactated Ringer's is not the solution of choice with this procedure.

120. The nurse has just received a unit of packed red blood cells from the blood bank for transfusion to an assigned client. The nurse is careful to select tubing especially made for blood products, knowing that this tubing is manufactured with: 1. An air vent. 2. An in-line filter. 3. A microdrip chamber. 4. Tinted tubing to protect the blood from light.

2. An in-line filter. The tubing used for blood administration has an in-line filter. The filter helps ensure that any particles larger than the size of the filter are caught in the filter and are not infused into the client. The tubing should be macrodrip, not microdrip, to allow blood to flow freely through the drip chamber. An air vent is unnecessary because the blood bag is not made of glass. Option 4 is incorrect because blood does not need to be protected from light.

129. A client with severe blood loss resulting from multiple trauma requires rapid transfusion of several units of blood. The nurse asks another health team member to obtain which device for use during the transfusion procedure to help reduce the risk of cardiac dysrhythmias? 1. Pulse oximetry 2. Cardiac monitor 3. Infusion controller 4. Blood-warming device

4. Blood-warming device If several units of blood are to be administered, a blood warmer should be used. Rapid transfusion of cool blood places the client at risk for cardiac dysrhythmias. To prevent this, the nurse warms the blood using a blood-warming device. Pulse oximetry and cardiac monitoring equipment are useful for the early assessment of complications but do not reduce the occurrence of cardiac dysrhythmias. Electronic infusion devices are not helpful in this case because the infusion must be rapid, and infusion devices generally are used to control the flow rate. In addition, not all infusion devices are made to handle blood or blood products.

126. A client is brought to the emergency department having experienced blood loss related to an arterial laceration. Fresh-frozen plasma is prescribed and transfused to replace fluid and blood loss. The nurse understands that the rationale for transfusing fresh-frozen plasma in this client is: 1. To treat the loss of platelets 2. To promote rapid volume expansion 3. That the transfusion must be done slowly 4. That it will increase the hemoglobin and hematocrit levels

2. To promote rapid volume expansion Fresh-frozen plasma is often used for volume expansion as a result of fluid and blood loss. It does not contain platelets, so it is not used to treat any type of low platelet count disorder. It is rich in clotting factors and can be thawed quickly and transfused quickly. It will not specifically increase the hemoglobin and hematocrit level.

119. 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 (IV) 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.

3. Run normal saline at a keep-vein-open rate. 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 inmaintaining 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.

121. A client has received a transfusion of platelets. The nurse evaluates that the client is benefiting most from this therapy if the client exhibits which of the following? 1. Increased hematocrit level 2. Increased hemoglobin level 3. Decline of elevated temperature to normal 4. Decreased oozing of blood from puncture sites and gums

4. Decreased oozing of blood from puncture sites and gums Platelets are necessary for proper blood clotting. The client with insufficient platelets may exhibit frank bleeding or oozing of blood from puncture sites, wounds, and mucous membranes. Increased hemoglobin and hematocrit levels would occur when the client has received a transfusion of red blood cells. An elevated temperature would decline to normal after infusion of granulocytes if those cells were instrumental in fighting infection in the body.

125. The nurse listening to morning report learns that an assigned client received a unit of granulocytes the previous evening. The nurse makes a note to assess the results of which of the following daily serum laboratory studies to assess the effectiveness of the transfusion? 1. Hematocrit level 2. Erythrocyte count 3. Hemoglobin level 4. White blood cell count

4. White blood cell count The client who has neutropenia may receive a transfusion of granulocytes, or white blood cells. These clientsoften have severe infections and are unresponsive to antibiotic therapy. The nurse notes the results of follow-up white blood cell counts to evaluate the effectiveness of the therapy. The nurse also continues to monitor the client for signs and symptoms of infection. Erythrocyte count and hemoglobin and hematocrit levels are determined after transfusion of packed red blood cells.