NUR 211 Blood Transfusion NCLEX Questions

A nurse is preparing medication for administration. In addition to the right medication, the nurse adheres to which of the following additional rights of medication administration. Select all that apply. a. The right route b. The right staff member c. The right time d. The right client e. The right documentation f. The right dose

A, C, D, E, F There are six rights to administering medications: The right medication, the right client, the right dose, the right route, the right time, and the right documentation.

A client receiving a transfusion of packed red blood cells (PRBCs) begins to vomit. The client's blood pressure is 90/50 from a baseline of 125/78. The client's temperature is 100.8F orally from a baseline of 99.2F orally. The nurse determines that the client may be experiencing which complication of a blood transfusion? a. Septicemia b. Hyperkalemia c. Circulatory overload d. Delayed transfusion reaction

A. 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 dysrythmias. Circulatory overload causes cough, dyspnea, chest pain, wheezing, tachycardia, and hypertension. A delayed transfusion reaction can occur days or weeks after a tranfusion. Signs include fever, mild jaundice, and a decreased hematocrit level.

The nurse has discontinued a unit of blood that was infusing into a client because the client experienced a transfusion reaction. After documenting the incident appropriately, the nurse sends the blood bag and tubing to which of the following departments? a. Blood bank b. Risk management c. Environmental services d. Infection control

A. blood bank The nurse returns the blood transfusion bag containing any remaining blood to the blood bank. This allows the blood bank to complete any follow-up testing procedures needed once a transfusion reaction has been documented. The other option identify incorrect departments.

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? a. Vital signs b. Skin color c. Urine output D. Latest hematocrit level

A. vital signs A change in VS 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 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? a. "have you ever had a transfusion before?" b. "why do you think that you need the transfusion?" c. "have you ever gone into shock for any reason in the past?" e. "do you know the complications and risks of a transfusion?"

a. "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 C and E 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 B is not an appropriate statement in terms of eliciting information from the client regarding an understanding of the need for the transfusion

The nurse is picking up a unit of packed red blood cells at the hospital blood bank. After putting the pen down, the nurse glances at the clock, which reads 1:00. The nurse calculates that the transfusion must be started by: a. 1:30 b. 2:00 c. 2:30 d. 3:00

a. 1:30 Blood must be hung as soon as possible within 30 mintues after it is obtained from the blood bank.

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? a. give an autologous blood donation before the surgery b. ask a friend or family member to donate blood ahead of time c. take iron supplements before surgery to boost hemoglobin levels d. request that any donated blood be screened twice by the blood bank.

a. 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 ask a family member to donate blood before surgery. Blood banks do not provide extra screening on request. Preoperative iron supplements are not helpful in replacing blood lost during the surgery.

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 100.6F orally. Which of the following is the appropriate nursing action? a. Begin the transfusion as prescribed b. Delay hanging the blood and notify the physician c. Administer an antihistamine and begin the transfusion d. Administer two tablets of acetaminophen (Tylenol) and begin the transfusion

b. Delay hanging the blood and notify the physician If the client's temperature is higher than 100F the unit of blood should not be hung until the physician is notified and has the opportunity to give further prescriptions. The physician will likely prescribe that the blood be administered regardless of the temperature, but the decision is not within the nurse's scope of practice to make.

A client has a prescription to receive a unit of packed red blood cells. The nurse should obtain which of the following IV solutions form the IV storage area to hang with the blood product at the client's bedside? a. Lactated Ringer's b. 0.9% sodium chloride c. 5% dextrose in 0.9% sodium chloride d. 5% dextrose in 0.45% sodium chloride

c. 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.

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? a. Increased hematocrit level b. Increased hemoglobin level c. Decline of elevated temperature to normal d. Decreased oozing of blood from puncture sites and gums

d. 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.

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: A. to treat the loss of platelets B. to promote rapid volume expansion C. That the transfusion must be done slowly D. That it will increase the hemoglobin and hematocrit levels.

B. 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.

A nurse has an order to transfuse a unit of packed red blood cells to a client who does not currently have an IV line inserted. When obtaining supplies to start the IV infusion the nurse selects an angiocatheter with a size of: a. 18 gauge b. 21 gauge c. 22 gauge d. 24 gauge

a. 18 gauge The IV catheter used for a blood transfusion should be at least 18 or 19 gauge. Compared with IV solutions, blood has a thicker and stickier consistency, and use of an 18 or 19 gauge catheter will ensure that the bore of the catheter is large enough to prevent damage to the blood cells.

A client has experienced a rash with pruritus during previous blood transfusions. The client asks the nurse whether it is safe to receive another transfusion. In formulating a response, the nurse incorporates the understanding that which medication will most likely be prescribed before the transfusion is begun? a. Ibuprofen (Motrin) b. Acetaminophen (Tylenol) c. Diphenhydramine (Benadryl) d. Acetylsalicylic Acid (ASA Aspirin)

c. Diphenhydramine (Benadryl) An urticarial reaction is characterized by a rash accompanied by pruritus. This type of transfusion reaction is prevented by pretreating the client with an antihistamine such as diphenhydramine. Acetaminophen and ASA are analgesics and ibuprofen is a NSAID