30 Chapter 30: Blood Therapy Perry et al.: Clinical Nursing Skills & Techniques, 9th Edition

6. Under the ABO system, the blood type __________ can be given to any individual and is known as the "Universal Donor."

ANS: O negative O negative can be given to people of any blood type and is known as the "Universal Donor."

3. Antibodies that react against the A and B antigens are naturally present in the plasma of people whose red blood cells do not carry the antigen. These antibodies react against the foreign antigens. Incompatible red blood cells clump together or _____________, which results in a life-threatening hemolytic transfusion reaction.

ANS: agglutinate Antibodies that react against the A and B antigens are naturally present in the plasma of people whose red blood cells do not carry the antigen. These antibodies (agglutinins) react against the foreign antigens (agglutinogens). Incompatible red blood cells agglutinate (clump together), which results in a life-threatening hemolytic transfusion reaction.

1. A transfusion in which the donor is the patient is known as an ______________ transfusion or autotransfusion.

ANS: autologous In autologous transfusion, or autotransfusion, the donor is the patient.

2. The presence or absence of specific antigens on the surface of red blood cells determines ___________________ in the ABO system.

ANS: blood type The presence or absence of specific antigens on the surface of red blood cells determines blood type in the ABO system.

4. The nurse is caring for a patient who is receiving blood while monitoring the patient for potential complications. The nurse knows that a systemic response to administration of a blood product that is incompatible with the blood of the recipient, contains allergens to which the recipient is sensitive or allergic, or is contaminated with pathogens is known as a _________.

ANS: hemolytic reaction A hemolytic reaction is a systemic response to the administration of a blood product that is incompatible with the blood of the recipient, contains allergens to which the recipient is sensitive or allergic, or is contaminated with pathogens.

5. The patient has received blood within the past 6 hours. The patient begins to feel short of breath and calls for the nurse. The nurse finds that the patient is dusky in color with crackles throughout his lungs and is coughing up pink frothy sputum. The nurse calls the physician immediately, knowing that the patient is showing signs of _________________.

ANS: transfusion-related acute lung injury (TRALI) transfusion-related acute lung injury Possible adverse outcomes that result from transfusion therapy include transmission of diseases, circulatory overload, and TRALI characterized by noncardiogenic pulmonary edema with onset within 6 hours of transfusion.

14. When a patient's adverse reaction to a blood transfusion is differentiated, which of the following signs/symptoms indicates the presence of an anaphylactic response? a. Wheezing and chest pain b. Headache and muscle pain c. Hypotension and tingling of the extremities d. Crackles in the lungs and increased central venous pressure

ANS: A Observe the patient for wheezing, chest pain, and possible cardiac arrest. All of these are indications of an anaphylactic reaction. Be alert to patient complaints of headache or muscle pain in the presence of a fever. Both may be indicative of a febrile nonhemolytic reaction. Observe patients receiving massive transfusions for mild hypothermia, cardiac dysrhythmias, hypotension, and hypocalcemia. Cold blood products can affect the cardiac conduction system, resulting in ventricular dysrhythmias. Other cardiac dysrhythmias, hypotension, and tingling may indicate hypocalcemia, which occurs when citrate (used as a preservative for some blood products) combines with the patient's calcium. Crackles in the bases of lungs and rising central venous pressure (CVP) are indications of circulatory overload.

12. The nurse is administering blood. What should the nurse do to detect a blood reaction as quickly as possible? a. Remain with the patient during the first 15 minutes. b. Transfuse the blood at 10 mL/min. c. Monitor vital signs q 1 hour. d. Transfuse blood at 50 gtt/min.

ANS: A Remain with the patient during the first 15 minutes of a transfusion. Most transfusion reactions occur within the first 15 minutes of a transfusion. The initial flow rate during this time should be 2 mL/min, or 20 gtt/min. Initially infusing a small amount of blood component minimizes the volume of blood to which the patient is exposed, thereby minimizing the severity of a reaction. Monitor the patient's vital signs at 5 minutes, at 15 minutes, and every 30 minutes until 1 hour after transfusion or per agency policy. Frequent monitoring of vital signs will help to quickly alert the nurse to a transfusion reaction.

16. The patient has been home from the hospital for 10 days. On the last day of his hospitalization, he received 2 units of packed red blood cells (RBCs). This morning, he noticed that his skin had a yellow tint to it and his temperature was elevated. Which reaction might this patient be experiencing? a. Delayed hemolytic transfusion reaction b. Acute hemolytic transfusion reaction c. Nonhemolytic febrile reaction d. Severe allergic transfusion reaction

ANS: A Symptoms of a delayed hemolytic reaction usually begin 2 to 14 days after the transfusion and include unexplained fever, unexplained decrease in Hgb/Hct, increased bilirubin levels, and jaundice. Symptoms of an acute hemolytic reaction usually begin within 15 minutes of transfusion initiation and include severe pain in the kidney area and chest, increased temperature (up to 105°F), increased heart rate, and increased sensation of heat and pain along the vein receiving blood, as well as chills, low back pain, headache, nausea, chest or back pain, chest tightness, dyspnea, bronchospasm, anxiety, hypotension, vascular collapse, disseminated intravascular coagulation, and possibly death. Symptoms of a nonhemolytic febrile reaction begin between 30 minutes after initiation and 6 hours after completion of transfusion and include fever greater than 1°C above baseline, flushing, chills, headache, and muscle pain; they occur most frequently in immunosuppressed patients. Symptoms of an acute severe allergic reaction usually begin within 5 to 15 minutes of initiation of transfusion and include coughing, nausea, vomiting, respiratory distress, wheezing, hypotension, loss of consciousness, and possible cardiac arrest.

1. For how long may blood preserved with citrate-phosphate-dextrose (CPD) be stored (unfrozen) before use? a. 21 days b. 35 days c. 42 days d. 3 months

ANS: A When preserved with citrate, phosphate, and dextrose, a unit of blood has a shelf life of 21 days (unfrozen).

2. What is the purpose of administering a transfusion? (Select all that apply.) a. Restore intravascular volume. b. Restore the oxygen-carrying capacity of blood. c. Provide clotting factors. d. Improve blood pressure.

ANS: A, B, C Transfusions are used to restore intravascular volume with whole blood or albumin, to restore the oxygen-carrying capacity of blood with red blood cells (RBCs), and to provide clotting factors and/or platelets. Although increasing blood volume may increase blood pressure, increasing blood pressure is not a primary objective of transfusion.

5. Symptoms that indicate an adverse reaction to blood products include which of the following? (Select all that apply.) a. Fever b. Skin rash c. Hypotension d. Cardiac arrest

ANS: A, B, C, D Symptoms that indicate an adverse reaction range from fever, chills, and skin rash to hypotension and cardiac arrest.

MULTIPLE RESPONSE 1. Transfusion therapy is the intravenous (IV) administration of which of the following? (Select all that apply.) a. Whole blood b. Plasma products c. Red blood cells (RBCs) d. Platelets

ANS: A, B, C, D Transfusion therapy or blood replacement is the intravenous (IV) administration of whole blood, its components, or plasma-derived product for therapeutic purposes.

4. The patient is receiving blood when he suddenly complains of low back pain and develops diaphoresis and chills. The nurse should: (Select all that apply.) a. stop the transfusion. b. start normal saline connected to the Y tubing. c. notify the physician. d. start normal saline using new intravenous (IV) tubing.

ANS: A, C, D If signs of a transfusion reaction occur, stop the transfusion, start normal saline with new primed tubing directly to the ventricular assist device (VAD) at the keep-vein-open rate (KVO), and notify the physician immediately.

11. The nurse is preparing to administer a unit of blood to a patient using blood tubing. On the blood product side of the Y tubing, the nurse will hang blood. What will be hung on the other side of the Y tubing? a. Dextrose 5% b. Normal saline c. Dextrose 10% d. Dextrose 5%/normal saline

ANS: B Normal saline is compatible with blood products, unlike solutions that contain dextrose, which causes coagulation of donor blood.

6. The patient has received a total of 7 units of blood over the past 8 hours. The nurse assesses the patient's laboratory test results. Which of the following would be an expected complication? a. Hypokalemia b. Hyperkalemia c. Hypercalcemia d. Iron deficiency

ANS: B When blood is stored, there is continual destruction of red blood cells (RBCs), which releases potassium from the cells into the plasma. If blood is transfused rapidly, transient hyperkalemia may occur before the potassium is reabsorbed. Blood that is preserved with citrate phosphate dextrose (CPD) contains a high concentration of citrate ions. The excess citrate may combine with the ionized calcium in the recipient's blood, resulting in transient low ionized calcium levels. Patients receiving multiple transfusions should be assessed for iron overload.

3. The patient is to receive 2 units of packed red blood cells (RBCs). Before administering the blood, what does the nurse need to do? (Select all that apply.) a. Insert an 18-gauge intravenous (IV) cannula. b. Have the patient complete a consent form. c. Obtain pretransfusion vital signs. d. Notify the physician for a temperature of 37°C.

ANS: B, C In emergency situations that require rapid transfusions, a large-gauge cannula is preferred; however, transfusions for therapeutic indications may be infused with cannulas ranging from 20 to 24 gauge. Check that the patient has properly completed and signed transfusion consent before retrieving blood. Most agencies require patients to sign consent forms before receiving blood component therapy because of the inherent risks. Obtain and record pretransfusion vital signs, including temperature, immediately before initiation of the transfusion. If the patient is febrile (temperature greater than 100°F [37.8°C]), notify the physician or the health care provider before initiating the transfusion. Change from baseline vital signs during infusion will alert the nurse to a potential transfusion reaction or adverse effect of therapy.

13. An appropriate technique for the nurse to implement for a blood transfusion is to: a. provide medication through the intravenous (IV) tubing with the blood. b. regulate the flow of blood so that it infuses over 8 hours. c. clear the IV tubing with normal saline after the blood infuses. d. administer a blood product with clots through a filter line.

ANS: C After the blood has infused, clear the IV line with 0.9% normal saline and discard the blood bag according to agency policy. Medication should never be injected into the same IV line as a blood component because of the risk of contaminating the blood product with pathogens and the possibility of incompatibility. A separate IV line must be maintained if the patient requires IV infusion (total parenteral nutrition, pain control) during the transfusion. A unit of blood should not hang for longer than 4 hours because of the danger of bacterial growth. Check the appearance of blood product for leaks, bubbles, clots, or a purplish color. Do not transfuse blood if its integrity is compromised. Blood serves as a medium for bacteria.

9. What primary intervention should a nurse who is preparing a blood transfusion perform? a. Set up the Y tubing. b. Obtain 0.9% saline. c. Verify the blood product and the patient. d. Have the patient void or empty the urine drainage container.

ANS: C Correctly verify the product and identify the patient with a person considered qualified by your agency. Strict adherence to verification procedures before administration of blood or blood components reduces the risk of administering the wrong blood to the patient. Clerical errors are the cause of most hemolytic transfusion reactions. Y tubing is used to facilitate maintenance of intravenous (IV) access in case a patient will need more than 1 unit of blood. However, the focus here is on prevention of possible blood reactions. Use of Y tubing will not prevent a blood reaction. Normal saline is compatible with blood products, unlike solutions that contain dextrose, which causes coagulation of donor blood. However, strict adherence to verification procedures before administration of blood or blood components reduces the risk of administering the wrong blood to the patient. Empty the urine drainage collection container or have the patient void. If a transfusion reaction occurs, a urine specimen containing urine produced after initiation of the transfusion will be sent to the laboratory.

17. The specific blood product used for replacement of clotting factors and fibrinogen is: a. whole blood. b. packed RBCs. c. cryoprecipitate. d. albumin, 25% pooled.

ANS: C Cryoprecipitate replaces factors VIII and XIII, von Willebrand's factor, and fibrinogen. It also replaces red cell mass and plasma volume and is expected to raise hemoglobin by 1 g/100 mL and hematocrit by 3% in a non-hemorrhaging adult. Using cryoprecipitate is the preferred method of replacing red blood cell mass.

8. The patient is scheduled to receive 1 unit of packed red blood cells (RBCs). She has small, fragile veins, and a 22-gauge intravenous (IV) patent catheter is in place. What should the nurse do? a. Cancel the blood transfusion. b. Insert a 16-gauge IV catheter into the antecubital fossa. c. Use the IV catheter that is in place. d. Transfuse the blood over 6 hours.

ANS: C In emergency situations that require rapid transfusions, a large-gauge cannula is preferred; however, transfusions for therapeutic indications may be infused with cannulas ranging from 20 to 24 gauge. Large-gauge cannulas (18 or 20 gauge) promote rapid flow of blood components. 16-Gauge catheters are used frequently in surgery, but not usually on acute care units. Blood must be transfused within 4 hours. Use of smaller-gauge cannulas, such as 24 gauge, often requires the blood bank to divide the unit so that each half can be infused within the allotted time or requires the use of pressure-assisted devices.

7. The patient is to receive 2 units of packed red blood cells (RBCs). The units are cold, and the nurse is concerned that this could lead to dysrhythmias and/or a reduction in core temperature. What action may the nurse take to prevent this? a. Warm the blood in a microwave. b. Warm the blood using hot water. c. Warm the blood using a blood warmer. d. Allow the blood to warm to room temperature before administering.

ANS: C In emergency situations, rapid transfusion of cold blood may lead to dysrhythmias and a reduction in core temperature. Sometimes a blood warmer machine is used for large transfusions of greater than 50 mL/kg/hr or in patients with cold agglutinins. Heating blood products in a microwave or with hot water is dangerous and may destroy blood cells. Blood must be given within a prescribed time frame. Allowing the blood to come to room temperature before administration would decrease the time available for administration.

10. The patient is to receive 1 unit of packed red blood cells (RBCs). The nurse obtains the blood from the blood bank and returns to the unit to find that the patient has been taken to radiology for a computed tomography (CT) scan and is expected to return in about an hour. What should the nurse do? a. Go to radiology and administer the blood. b. Keep the blood refrigerated until the patient returns. c. Return the blood to the blood bank. d. Hang the blood in the patient's room and start it when the patient returns.

ANS: C Initiate the blood transfusion within 30 minutes of the time of release from the blood bank. If the blood cannot be started because the patient is in the bathroom or the physician has to be notified of an elevated temperature, immediately return the blood to the blood bank, and retrieve it when it can be administered.

4. The patient is brought to the emergency department after a motor vehicle accident and has lost a large volume of blood. The patient's blood type is AB. Which blood type may this patient safely receive in transfusion? a. Only type AB blood b. Only type O blood c. All blood types d. Only type A blood

ANS: C People with type AB blood have neither antibodies and therefore can receive all blood types.

15. The patient is receiving a unit of packed red blood cells (RBCs). Fifteen minutes into the procedure, he complains of severe kidney pain, and his temperature increases by 3°F. The nurse stops the transfusion immediately, suspecting that which of the following reactions is occurring? a. Delayed hemolytic transfusion reaction b. Nonhemolytic febrile reaction c. Acute hemolytic transfusion reaction d. Severe allergic reaction

ANS: C Symptoms of an acute hemolytic reaction usually begin within 15 minutes of transfusion initiation and include severe pain in the kidney area and chest, increased temperature (up to 105°F), increased heart rate, and a sensation of heat and pain along the vein receiving blood, as well as chills, low back pain, headache, nausea, chest or back pain, chest tightness, dyspnea, bronchospasm, anxiety, hypotension, vascular collapse, disseminated intravascular coagulation, and possibly death. Symptoms of a delayed hemolytic reaction usually begin 2 to 14 days after the transfusion and include unexplained fever, an unexplained decrease in hemoglobin/hematocrit (Hgb/Hct), increased bilirubin levels, and jaundice. Symptoms of a nonhemolytic febrile reaction begin between 30 minutes after initiation and 6 hours after completion of transfusion and include fever greater than 1°C above baseline, flushing, chills, headache, and muscle pain; they occur most frequently in immunosuppressed patients. Symptoms of an acute severe allergic reaction usually begin within 5 to 15 minutes of initiation of transfusion and include coughing, nausea, vomiting, respiratory distress, wheezing, hypotension, loss of consciousness, and possible cardiac arrest.

18. The nurse is administering 1 unit of packed red blood cells as ordered by the primary care provider. While the nurse is measuring vital signs 15 minutes after starting the transfusion, the patient complains of chills and back pain. What is the nurse's first action? a. Stop the blood transfusion and keep the vein patent by administering saline to infuse from the other side of the Y tubing. b. Slow the blood transfusion and notify the charge nurse. c. Disconnect the blood tubing from the catheter and replace it with an infusion of normal saline. d. Stop the blood transfusion and notify the primary care provider.

ANS: C The nurse's first priority is to stop the blood transfusion. To keep the intravenous site patent, normal saline can be infused at a keep-open rate, but the tubing must be changed to avoid administering more blood as the saline flushes the blood from the tubing. If the tubing is not changed, additional blood will be administered, and the possible transfusion reaction will increase. The charge nurse or the primary care provider should be notified only after the patient has been assessed.

5. The patient is scheduled to receive a blood transfusion. Preadministration laboratory tests are run to assess the level of which component in the patient's blood? a. Sodium (Na) b. Calcium (Ca) c. Potassium (K) d. Iron (Fe)

ANS: C When blood is stored, there is continual destruction of red blood cells (RBCs), which releases potassium from the cells into the plasma. If blood is transfused rapidly, transient elevated potassium levels may occur before the potassium is reabsorbed and put the patient at risk.

2. The nurse is caring for a patient who needs a blood transfusion. The patient has been tested and was found to have blood type O. The nurse knows this means that which antigen is present on the surface of the red blood cells? a. The type A antigen is present. b. The type B antigen is present. c. Neither type A nor type B antigens are present. d. Both type A and type B antigens are present.

ANS: C When neither A nor B antigens are present, the blood group is type O. When the type A antigen is present, the blood group is type A. When the type B antigen is present, the blood group is type B. When both A and B antigens are present, the blood group is type AB.

3. A nurse is concerned about the type of blood that a patient is to receive. A patient with an O blood type may safely receive which type of blood? a. Type A blood b. Type B blood c. Type AB blood d. Type O blood

ANS: D People with type O blood have both A and B antibodies and therefore can receive only type O blood. People with type A blood have anti-B antibodies and therefore can receive only type A blood. People with type B blood have anti-A antibodies and therefore can receive only type B blood. People with type AB blood have neither antibodies and therefore can receive all blood types.