Blood Transfusion WS + Quiz

What preparation for blood transfusion administration must be done by the RN prior to initiating the blood transfusion? Select all that apply. (Ignatavicius et al., 2021, p. 816-17) Assess lung sounds and fluid volume status Assess vital signs immediately prior to start of transfusion Confirm blood transfusion consent form is signed Assess medication allergies Assess lab value(s) verifying indication for ordered blood product Assess IV access site is patent and intact Assess oral medications prescribed for client Assess for prior blood transfusion and/or reaction Check the healthcare provider order

-Assess lung sounds and fluid volume status -Assess vital signs immediately prior to start of transfusion -Confirm blood transfusion consent form is signed -Assess lab value(s) verifying indication for ordered blood product -Assess IV access site is patent and intact -Assess for prior blood transfusion and/or reaction -Check the healthcare provider order -Medication allergies and oral medications that the client is prescribed and taking do not apply specifically to the blood transfusion. While these are things that we would know about our client, they are not necessary information specifically needed prior to infusing blood.

What considerations should the RN make for the older adult receiving a transfusion? Select all that apply. (Ignatavicius et al., 2021, p. 818) Assess vital signs every 15-30 minutes throughout transfusion Administer stool softeners as prescribed Assess the clients history of heart failure or renal disease prior to administration Administer blood product slowly, over 2-4 hours per unit If possible, allow 2 full hours after infusing 1 unit of blood before infusing the next unit Avoid concurrent fluid administration into any other IV site

-Assess vital signs every 15-30 minutes throughout transfusion -Assess the clients history of heart failure or renal disease prior to administration -Administer blood product slowly, over 2-4 hours per unit -If possible, allow 2 full hours after infusing 1 unit of blood before infusing the next unit -Avoid concurrent fluid administration into any other IV site

If a blood transfusion reaction is suspected, the RN will do which of the following. Select all that apply. (Ignatavicius et al., 2021, p. 820, PowerPoint) Disconnect blood administration set from the IV catheter Administer IV methylprednisolone Call healthcare provider and blood bank Assess vital signs Verify and review blood product with name, birthdate, medical record number, blood type and Rh factor, donor number, blood bank number, and expiration date Infuse new bag of 0.9% sodium chloride, using new tubing Return blood bag and tubing to the blood bank Stop the transfusion

-Disconnect blood administration set from the IV catheter -Call healthcare provider and blood bank -Assess vital signs -Infuse new bag of 0.9% sodium chloride, using new tubing -Verify and review blood product with name, birthdate, medical record number, blood type and Rh factor, donor number, blood bank number, and expiration date -Return blood bag and tubing to the blood bank -Stop the transfusion

What items by the RN must be verified before administration of the blood product? Select all that apply. (PowerPoint and Evaluation Rubrics) Donor unit number Full first name and last name Type of blood product (such as packed red blood cells) Medical record number Blood bank number ABO blood type / Rh Medication allergies Expiration date Birthdate

-Donor unit number -Full first name and last name -Type of blood product (such as packed red blood cells) -Medical record number -Blood bank number -ABO blood type / Rh -Expiration date -Birthdate All are part of the verification process except medication allergies. This does not pertain to blood product infusion.

If the RN suspects that the client is developing transfusion associated circulatory overload (TACO), the RN will identify which associated signs and symptoms may be present. Select all that apply. (Ignatavicius et al., 2021, p. 820, Blood handout) Jugular venous distention Dyspnea Weak, thready pulse Crackles Hypertension Restlessness

-Jugular venous distention -Dyspnea -Crackles -Hypertension -Restlessness -Manage and prevent TACO by: -monitoring I/O -assessing vitals and lungs sounds -infusing blood products slowly (but within the 4 hour maximum) -and/or administering diurectics if ordered by HCP before, between, or after units of blood.

The RN is providing education to the client regarding blood transfusion. What education will the RN include in the teaching plan prior to blood administration. Select all that apply. (American Red Cross Brochure, PowerPoint) How to manage side effect of nausea during transfusion Signs and symptoms of transfusion reaction How long blood product will be infusing Blood donation and screening process Blood product type ordered by the healthcare provider

-Signs and symptoms of transfusion reaction -How long blood product will be infusing -Blood donation and screening process -Blood product type ordered by the healthcare provider -Nausea should not be a side effect experienced during transfusion and therefore the RN would not educate about this. All other educational points are appropriate

The RN is teaching a client about rare but possible signs of an acute hemolytic blood transfusion reaction. The RN includes which of the following signs and/or symptoms. Select all that apply. (Blood product handout) Nausea and vomiting Tachypnea Dyspnea Chills Tachycardia Flushing Fever

-Tachypnea -Dyspnea -Chills -Tachycardia -Flushing -Fever

What IV solution is used to administer blood products? (Ignatavicius et al., 2021, p. 816) Lactated Ringers Dextrose 5% Sodium Chloride 0.9% Sodium Chloride 0.45% Sodium Chloride

0.9% Sodium Chloride

The RN is assessing blood compatability while verifying the unit of packed red blood cells. The clients blood type is A-. This client can receive what blood product(s). Select all that apply. (Ignatavicius et al., 2021, p. 818, PowerPoint) AB- A+ A- O+ O-

A- O-

The RN is assessing blood compatability while verifying the unit of packed red blood cells. The clients blood type is AB+. This client can receive what blood product(s). Select all that apply. (Ignatavicius et al., 2021, p. 818, PowerPoint) B+ B- A- O- O+ A+ AB- AB+

B+ B- A- O- O+ A+ AB- AB+

What is the first step in blood administration? Ensure that you have IV access (19 gauge or larger) Check for MD order Educate the client on blood transfusion and signs or symptoms of reaction Gather the needed supplies

Check for MD order

A client receiving a blood transfusion complains of chills, headache, backache, and suddenly spikes a temperature. The priority nursing action is to? Flush the tubing with normal saline Slow the transfusion Discontinue the transfusion Continue to monitor the client

Discontinue the transfusion

In a non-emergent situation, any hospital employee may obtain blood from the blood bank. (Ignatavius et al., 2021, p. 816) True False

False -Typically in emergency situations, this would be true. In non-emergent situations, follow the hospital policies which may allow LPNs and UAPs to also get the blood from the blood bank. Some facilities require only RNs to obtain the blood.

The total time a nurse has from obtaining the blood in the blood bank to completing the transfusion is 6 hours. (PowerPoint, blood transfusion evaluation rubric) True False

False -is 4 hours

An 88-year-old patient who underwent internal fixation of a fractured hip 3 days ago now has a Hgb level of 7.8 g/dl. The doctor prescribes 2 Units of packed RBCs to run over 3 hours each. When preparing the administration set you should? Piggyback blood into an existing IV line Have normal saline solution (0.9% NaCl) set up in the primary IV tubing Hang dextrose 5% in water as a piggyback infusion through a secondary I.V. set Have lactated ringers solution set up in primary line

Have normal saline solution (0.9% NaCl) set up in the primary IV tubing

The nurse is observing another nurse administer blood. Which of the following indicates to the observing nurse that the administering nurse does not understand blood administration? Run the blood slowly for the first 15 minutes at 1 ml/minute. Establish the required flow rate after 15 minutes if no signs of reaction. Infuse the transfusion slowly over 6 hours. Assess the vital signs every 15-30 minutes during the first hour (per hospital policy).

Infuse the transfusion slowly over 6 hours.

The RN is assessing blood compatability while verifying the unit of packed red blood cells. The clients blood type is B+. This client can receive what blood product(s). Select all that apply. (Ignatavicius et al., 2021, p. 818, PowerPoint) O- B- B+ AB- O+ AB+

O- B- B+ O+

The nurse is preparing to hang which of the following for a client with thrombocytopenia? Whole blood Packed red blood cells Platelets Albumin

Platelets

If the RN suspects a blood transfusion reaction, the RNs first action is: Stop the IV infusion Slow the IV infusion rate Call the healthcare provider Assess vital signs

Stop the IV infusion

An informed consent for a transfusion may be obtained by the RN after affirmation of consent has been completed by the healthcare provider. True False

True

The RN who will infuse the blood product must be one of two RN's comparing the clients identification with the information on the blood component bag and completing the dual verification process. (Ignatavicius et al., 2021, p. 817) True Flase

True

When the RN is starting the transfusion of blood products, the infusion flow rate will be 1 mL/min for the first 15 minutes of the transfusion. (Blood transfusion evaluation rubrics) True False

True

Never add or infuse other drugs with blood products because they may clot the blood during transfusion. (Ignatavicius et al., 2021, p. 817) True False

True -Plan accordingly to infuse any other IV meds prior to starting blood transfusion. For example, if an IV antibiotic is due or IV pain meds are needed, administer those prior to starting infusion of the blood product.

The RN will remain in the room with the client during the first 15 minutes of the blood transfusion per facility policy. (Ignatavicius et al., 2021, pp. 816-817) True False

True -The RN will follow the facility policy and remain in the room with the client during the first 15 minutes of the tranfusion. Vital signs are usually assessed every 5 minutes for the first 15 minutes (per facility policy).

When deciding IV catheter size for blood product administration, the RN will ideally select 20 gauge or larger. (Ignatavicius et al., 2021, pp. 816-817, Blood transfusion evaluation rubric) True False

True*** This is per facility policy, but typically 20 gauge or larger will infuse with an easier flow rate (blood products are more viscous). The larger size is usually more ideal to prevent catheter occlusion and/or to have the ability to run at a more rapid rate if needed.