Blood administration Quiz ATI

A nurse is preparing to administer 2 units of packed RBCs to an older adult client. Which of the following actions should the nurse take?

If possible, the nurse should wait 2 hr to elapse after the administration of the first unit of packed RBCs before beginning to infuse the second unit. This will decrease the client's risk of fluid overload. The nurse should obtain a new infusion set for each unit of packed RBCs. The nurse should administer blood to the older adult client slowly, taking as long as 4 hr per unit. The filter on the blood infusion set is only effective for 4 hr, so blood should not infuse for greater than 4 hr per unit. The nurse should monitor the vital signs of an older adult client receiving packed RBCs every 15 min during the transfusion. Changes in these parameters are crucial in detecting a circulatory overload transfusion reaction, which is much more common in the older adult client.

A nurse is preparing to administer one unit of packed RBCs to a client who has anemia. Which of the following actions should the nurse take?

It is the responsibility of the nurse who will be administering the blood product to enlist a second nurse to compare the client's identification with the information on the blood component bag. The nurse should obtain the client's vital signs immediately before starting a blood product infusion. The nurse should obtain the client's vital signs again after 15 min of infusion time. The nurse should prime the Y-line tubing with 0.9% sodium chloride. Use of dextrose 5% in water can cause clotting or hemolysis of blood cells. The nurse should assess the client's urine output as part of gathering baseline information, but it is not necessary to have the client to empty his bladder prior to beginning the transfusion.

A nurse is caring for a client who is receiving a unit of packed RBCs. The client states that he is experiencing flank pain and that it feels like his heart is racing. Which of the following types of transfusion reactions should the nurse identify the client is experiencing? A) Allergic B)Hemolytic C) Circulatory overload D)Febrile

B) Hemolytic The nurse should identify the manifestations of flank pain and tachycardia as a hemolytic transfusion reaction. Other manifestations can include fever, chills, hypotension, apprehension, and reddish or brown urine.

Blood Transfusion Reactions

Circulatory overload - can occur when a blood product is infused too quickly. Manifestations of circulatory overload can include dyspnea, hypotension, hypertension, crackles, distended neck veins, and confusion. A febrile transfusion reaction often occurs in clients who have had multiple transfusions or platelet transfusions. This type of reaction includes manifestations of a high fever, chills, vomiting, diarrhea, and hypotension. An allergic transfusion reaction can be mild, which would include manifestations of flushing and urticaria, or it can be severe, which would include manifestations of anaphylaxis, such as dyspnea, stridor, and chest pain.

Administration of Platelets

Platelets can be pooled from multiple donors and do not require the same blood type as the client. Platelets are fragile and the nurse should administer them immediately after they are brought to the client's room. The nurse should infuse the platelets over a period of 15 to 30 min.

A nurse is preparing to administer platelets to a client who has thrombocytopenia. Which of the following actions should the nurse take?

The nurse should administer platelets with a special transfusion set that has a smaller filter and shorter tubing. If a standard blood administration set is used, the filter can trap the platelets and the longer tubing increases platelet adherence to the lumen.

A nurse is providing teaching to a client who is scheduled to receive one unit of packed RBCs. Which of the following information should the nurse include in the teaching?

The nurse should inform the client that he will remain with the client for the first 15 min of the transfusion. It is during the first 50 mL of the transfusion that a severe reaction is most likely to occur. The nurse should inform the client that he should assume a comfortable position for the duration of the infusion, which can include lying or sitting. The client does not need to lie on his left side. The nurse should inform the client to contact the nurse immediately for any unusual manifestations, such as back pain, as this can be an indication of a transfusion reaction. The nurse should inform the client that the blood will infuse in 4 hr or less and that the remaining blood product will be discontinued at that time.