blood transfusion practice q

A client has a prescription to receive a unit of packed red blood cells. The nurse should obtain which intravenous (IV) solution from the IV storage area to hang with the blood product at the client's bedside?

0.9% sodium chloride

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?

15 minutes

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:

18 gauge

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:

1:30

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 which item?

An in-line filter

A nurse is caring for a client who has an upper gastrointestinal bleed and a hematocrit of 24%. Prior to inititating a transfusion of packed red blood cells, which of the following actions should the nurse take. SATA

Assess and document the client's vital signs Verify with another nurse the blood type and Rh of the packed RBCs Change IV tubing to a set that has a filter

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?

Blood-warming device

A nurse is preparing to administer packed RBCs to a client who is anemic. Which of the following actions should the nurse take? Select all that apply

Check to determine the packed RBCs are less than 1 week old Ask another nurse to check the packed RBCs label against the medical record Prime the transfusion tubing with 0.9% sodium chloride

A nurse is assessing a child who is postoperative and received a unit of packed RBCs during a surgical procedure. Which of the following findings indicates the child is experiencing a hemolytic transfusion reaction?

Chills and flank pain

A nurse is caring for a postoperative client who has an Hgb of 8.0 g/dL. The nurse delegates the administration of a unit of packed RBCs to a nurse floating from a psychiatric unit who is unfamiliar with blood administration. Which of the following actions should the float nurse take?

Decline to hang the blood

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 record 100.6 F orally. Which action should the nurse take?

Delay hanging the blood and notify the health care provider

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?

Diphenhydramine (Benadryl)

A nurse is providing preoperative teaching to a client who is scheduled for arthroplasty in the next month and may require a blood transfusion. The client expresses concern about the risk of acquiring an infection from the blood transfusion. Which of the following statements should the nurse share with the client?

Donate autologous blood before surgery

A nurse is caring for a client who is 2 hours postpartum and is exhibiting signs of hypovolemic shock. Which of the following actions should the nurse take?

Elevate the client's legs to a 30 degree angle

The nurse who is about to begin a blood transfusion knows that blood cells start to deteriorate after a certain period of time. Which item is important to check regarding the age of blood cells before the transfusion is begun?

Expiration date

The nurse has received a prescription to transfuse a client with a unit of packed RBCs. Before explaining the procedure to the client, the nurse should ask which initial question?

Have you ever had a transfusion before?

A nurse is caring for a client who is receiving a blood transfusion. The client reports flank pain, and the nurse notes reddish-brown urine in the client's urinary catheter bag. The nurse recognizes these manifestations as which of the following types of transfusion reactions?

Hemolytic

Following infusion of a unit of packed red blood cells, the client has developed new onset of tachycardia, bounding pulses, crackles, and wheezes. Which action should the nurse implement FIRST?

Place the client in high-Fowler's position

A nurse is transfusing a unit of B-positive fresh frozen plasma to a client who is blood type is O-negative. Which of the following actions should the nurse take?

Remove the unit of plasma immediately and start an IV infusion of normal saline solution

The nurse determines that a client is having a transfusion reaction. After the nurse stops the transfusion, which action should be taken NEXT?

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

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 which is the rationale for transfusing fresh-frozen plasma to this client?

To promote rapid volume expansion

A nurse observes tachycardia, dyspnea, a cough, and distended neck veins in a client who is receiving a transfusion of packed red blood cells (RBCs). Which of the following interventions should the nurse use to prevent these manifestations with the client's next transfusion?

Use a transfusion pump to regulate and maintain the transfusion at a slower rate

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 should assess which PRIORITY item?

Vital signs

a nurse is preparing to transfuse a unit of packed red blood cells for a client who has anemia. Which of the following actions should the nurse take first?

Witness the informed consent document

A nurse is planning care for a client who is pregnant and is Rh-negative. In which of the following situations should the nurse administer Rh(D) immune globulin?

at 28 weeks gestation

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?

blood banks

A nurse is assessing a client who is receiving a unit of whole blood. Which of the following findings should the nurse identify as a manifestation of a hemolytic transfusion reaction?

low back pain

A nurse is assessing a client who is receiving a transfusion of packed red blood cells. Which of the following findings should the nurse identify as an indication of an acute intravascular hemolytic reaction?

sudden oliguria