Blood Administration Nclex Review

The nurse is assisting with caring for a client who has received a transfusion of platelets. The nurse determines that the client is benefiting most from this therapy if the client exhibits which finding?

A decrease in oozing from puncture sites and gums

The nurse is monitoring a client who is receiving a unit of packed red blood cells. Within an hour after the initiation of a transfusion, the nurse finds the client to be restless, with reports of chills and back pain. The nurse notes that there is dark urine in the Foley catheter drainage bag. The nurse interprets that the client is experiencing which reaction?

Acute hemolytic

The primary health care provider prescribes one unit of packed red blood cells to infuse over 4 hours. One unit of blood contains 250 mL, and the drop factor is 10 gtt/1 mL. Although an infusion pump will be used, the registered nurse asks the licensed practical nurse (LPN) to assist with monitoring the flow rate during the infusion. The LPN monitors the flow rate, knowing that how many gtt/min should infuse? Fill in the blank and round answer to the nearest whole number.

10 gtt/min

A client is going to be transfused with a unit of packed red blood cells (PRBCs). The nurse understands that it is necessary to remain with the client for what time period after the transfusion is started?

15 minutes

A registered nurse has just hung a 250-mL bag of packed red blood cells (PRBCs) on a client. The licensed practical nurse assisting in caring for the client plans to remain with the client for at least how many minutes following the start of the infusion?

15 minutes

One unit of packed red blood cells is infusing into a client over a 4-hour period. The unit of blood contains 250 mL. The drop factor is 15 drops (gtt) per 1 mL. The nurse determines that the flow rate should be set at how many drops per minute? Fill in the blank and round answer to the nearest whole number.

16 gtt/min

The licensed practical nurse is assisting the registered nurse (RN) in the care of a child who is receiving a blood transfusion and notifies the RN if the child displays which signs/symptoms of fluid overload? Select all that apply.

4.Dry cough 5.Distended neck veins

A client receiving a blood transfusion begins to exhibit flushing, stridor, and a drop in blood pressure. The nurse should obtain which medication from the emergency cart to have ready for use as prescribed?

Epinephrine

A client wishes to donate blood for a family member and asks the nurse about the procedure for identifying compatibility. The nurse tells the client that which test will be done to test compatibility?

Indirect Coombs

The nurse is monitoring a client receiving a blood transfusion for circulatory overload. The nurse understands that which is a clinical indication of circulatory overload?

Moist, productive cough

One unit of packed red blood cells has been prescribed for a client postoperatively because the client's hemoglobin level is low. The primary health care provider prescribes diphenhydramine to be administered before the administration of the transfusion. Why is this medication being given?

Prevent a rash and pruritus

The nurse is assisting in the preparation of a client for a blood transfusion. Which item is the most important for the completion of the identification process?

Identification bracelet

A client who was receiving a blood transfusion has experienced a transfusion reaction. The nurse sends the blood bag that was used for the client to which area?

The blood bank

The nurse takes a client's temperature before giving a blood transfusion. The temperature is 100° F (37.7° C) orally. The nurse reports the finding to the registered nurse (RN) and anticipates that which action will take place?

The blood will be held, and the primary health care provider (PHCP) will be notified.

The nurse enters a client's room to check the client who began receiving a blood transfusion 45 minutes earlier. The client is flushed and dyspneic. The nurse listens to the client's lung sounds and notes the presence of crackles in the lung bases. The nurse determines that this client is most likely experiencing which complication of blood transfusion therapy?

Fluid (circulatory) overload

A client who is receiving a blood transfusion pushes the call light for the nurse. When entering the room, the nurse notes that the client is flushed, dyspneic, and complaining of generalized itching. How should the nurse correctly interpret these findings?

Transfusion reaction

The nurse is assisting with caring for a client who will receive a unit of blood. Just before the infusion, it is most important for the nurse to check which item?

Vital signs

A client requiring upcoming surgery is extremely anxious about the need for a possible blood transfusion and is concerned about the risk of infection from contaminated blood. The nurse suggests that the client consider which as an effective method to minimize this risk?

Arrange an autologous blood donation before the planned surgery.

The nurse is assisting in monitoring a client who is receiving a transfusion of packed red blood cells. Before leaving the room, the nurse tells the client that it is important to immediately report which sign if it occurs?

Backache

When assisting in the identification process required before a blood transfusion, which action will the nurse take when it is noted that all of the necessary information is correct, except for the client's name?

Call the blood bank about the discrepancy.

The nurse is assisting with caring for a client who is receiving a unit of packed red blood cells (PRBCs). The nurse should tell the client that it is most important to report which sign(s) immediately?

Chills, itching, or rash