ch 11 Blood Transfusions
how many mL in a unit of packed red blood cells (PRBCs)?
250-350 mL
blood must be transfused within what time period?
4 hours
at what rate do you transfuse blood and PRBCs?
-2 hrs/unit (usually) -must be infused within 4 hrs -first 15 min: 1-2 mL/min (reaction) (ATI Pharm p 209)
which diseases is donated blood screened for? (6)
-Hepatitis B -Hepatitis C -HIV -West Nile virus -Syphilis -Human T-cell lymphotropic virus
indications for packed red blood cells (PRBCs) (3)
-blood loss -anemia (Hgb < 6 g/dL) -kidney failure
fluid/circulatory overload: respiratory symptoms (4)
-crackles -dyspnea -wheezing -cough
septicemia: symptoms (6)
-fever (rapid onset) -chills (rapid onset) -vomiting -diarrhea -hypotension -shock
febrile reaction: symptoms (4)
-fever (↑ 1°C) -chills -headache -vomiting
acute hemolytic reaction: symptoms (6)
-flank pain/low back pain (kidneys) -fever -chills -dyspnea -tachycardia -hypotension
what to double check with another RN pre-transfusion (6)
-provider's order -transfusion consent form -pt ID -unit number -blood type -expiration
fluid/circulatory overload: nursing interventions (4)
-slow rate of transfusion or stop infusion (depending on severity of symptoms) -position pt upright with feet in dependent position (to facilitate breathing) -administer oxygen -administer diuretics
anaphylactic reaction: nursing interventions (3)
-stop the transfusion -keep line open with 0.9% sodium chloride -administer epinephrine
anaphylactic reaction: symptoms (4)
-urticaria -wheezing/bronchospasm -hypotension -shock
type of filter used for blood transfusions
in-line filter
fluid/circulatory overload: cardiovascular symptoms (4)
-tachycardia -bounding pulse -hypertension -distended neck veins (jugular venous distention)
thrombocytopenia
abnormally small number of platelets in the blood
A person with group O blood type may receive which of the following RBCs? a. group A only b. group O only c. group AB and O d. any blood group
b. group O only IV book
A nurse is providing preoperative teaching for a client who requests autologous donation in preparation for a scheduled orthopedic surgical procedure. Which of the following statements should the nurse include in the teaching? A. "You should make an appointment to donate blood 8 weeks prior to the surgery." B. "If you need an autologous transfusion, the blood your brother donates can be used." C. "You can donate blood each week if your hemoglobin is stable." D. "Any unused blood that is donated can be used for other clients."
C. "You can donate blood each week if your hemoglobin is stable." (beginning 6 weeks prior to surgery, the pt can donate blood if his Hgb and Hct remain stable) ATI MS
catheter gauge for blood transfusions
18-20 gauge (don't use larger than 19-gauge for older pts)
febrile reaction: nursing interventions (4)
-stop transfusion -keep line open with 0.9% sodium chloride -administer antipyretics (ex: acetaminophen) -restart transfusion slowly (if ordered)
mild allergic reaction: nursing interventions (5)
-stop transfusion -keep line open with normal saline -administer antihistamines (ex: Benadryl) -restart infusion slowly -administer antihistamines before transfusion if pt has hx of allergic reaction
each unit of blood will raise a pt's Hct by how much?
3%
A nurse is caring for a client who is receiving a blood transfusion. Which of the following actions should the nurse expect if an allergic transfusion reaction is suspected? (Select all that apply.) A. Stop the transfusion. B. Monitor for hypertension. C. Maintain an IV infusion with 0.9% sodium chloride. D. Position the client in an upright position with the feet lower than the heart. E. Administer diphenhydramine.
A. Stop the transfusion. C. Maintain an IV infusion with 0.9% sodium chloride. E. Administer diphenhydramine. (allergic reaction = hypotension; position pt upright for fluid overload, not allergic reaction) ATI MS
A nurse is preparing to administer packed RBCs to a client who has a Hgb of 8 g/dL. Which of the following actions should the nurse plan to take during the first 15 min of the transfusion? A. Obtain consent from the client for the transfusion. B. Assess for an acute hemolytic reaction. C. Explain the transfusion procedure to the client. D. Obtain blood culture specimens to send to the lab.
B. Assess for an acute hemolytic reaction. ATI MS
each unit of blood will raise a pt's Hgb by how many points?
1 g/dL
how often to check pt's vitals during a transfusion
-every 30 min - 1 hr according to facility policy (NCLEX) -every 15 min (ATI MS)
mild allergic reaction: symptoms (3)
-flushing -itching -urticaria
The nurse has received a prescription to transfuse a client with a unit of packed red blood cells. Before explaining the procedure to the client, the nurse should ask which initial question? 1. "Have you ever had a transfusion before?" 2. "Why do you think that you need the transfusion?" 3. "Have you ever gone into shock for any reason in the past?" 4. "Do you know the complications and risks of a transfusion?"
1. "Have you ever had a transfusion before?" NCLEX
how many mL in a unit of whole blood?
500 mL
autologous donation
a donation of the pt's own blood before a scheduled procedure - reduces the risk of disease transmission and potential transfusion complications
Which characteristics are related to an acute hemolytic transfusion reaction? (Select all that apply) a. ABO incompatibility b. hypothermia common c. destruction of donor RBCs d. acute kidney injury occurs e. hypocalcemia and hyperkalemia f. epinephrine used for severe reaction
a. ABO incompatibility c. destruction of donor RBCs d. acute kidney injury occurs MS workbook
Which of the following diseases is donor blood screened for? (Select all that apply) a. Hepatitis B b. West Nile virus c. Crohn's disease d. Epstein-Barr virus (EBV)
a. Hepatitis B b. West Nile virus IV book
The universal donor is a person with blood type: a. A-positive b. AB-positive c. O-negative d. AB-negative
c. O-negative IV book
A nurse is caring for a client who has an activated partial thromboplastin time (aPTT) greater than 1.5 times the expected reference range. Which of the following blood products should the nurse prepare to transfuse? a. whole blood b. platelets c. fresh frozen plasma d. packed red blood cells
c. fresh frozen plasma (FFP replaces coagulation factors and can help prevent bleeding) ATI Pharm
indication for platelets
thrombocytopenia
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? 1. Lactated Ringer's 2. 0.9% sodium chloride 3. 5% dextrose in 0.9% sodium chloride 4. 5% dextrose in 0.45% sodium chloride
2. 0.9% sodium chloride NCLEX
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? 1. 5 minutes 2. 15 minutes 3. 30 minutes 4. 45 minutes
2. 15 minutes
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? 1. To treat the loss of platelets 2. To promote rapid volume expansion 3. Because a transfusion must be done slowly 4. Because it will increase the hemoglobin and hematocrit levels
2. To promote rapid volume expansion
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? 1. Skin color 2. Vital signs 3. Urine output 4. Latest hematocrit level
2. Vital signs NCLEX
The nurse enters a client's room to assess the client, who began receiving a blood transfusion 45 minutes earlier, and notes that the client is flushed and dyspneic. On assessment, the nurse auscultates the presence of crackles in the lung bases. The nurse determines that this client most likely is experiencing which complication of blood transfusion therapy? 1. Bacteremia 2. Hypovolemia 3. Circulatory overload 4. Transfusion reaction
3. Circulatory overload
One unit of packed red blood cells has been prescribed for a client with severe anemia. The client has received multiple transfusions in the past, and it is documented that the client has experienced urticaria-type reactions from the transfusions. The nurse anticipates that which medication will be prescribed before administration of the red blood cells to prevent this type of reaction? 1. Ibuprofen (Motrin IB) 2. Acetaminophen (Tylenol) 3. Acetylsalicylic acid (aspirin) 4. Diphenhydramine (Benadryl)
4. Diphenhydramine (Benadryl) NCLEX
The nurse, listening to the morning report, learns that an assigned client received a unit of granulocytes the previous evening. The nurse makes a note to assess the results of which daily serum laboratory studies to assess the effectiveness of the transfusion? 1. Hematocrit level 2. Erythrocyte count 3. Hemoglobin level 4. White blood cell count
4. White blood cell count
A nurse is monitoring a client who began receiving a unit of packed RBCs 10 min ago. Which of the following findings should the nurse identify as an indication of a febrile transfusion reaction? (Select all that apply.) A. Temperature change from 37° C (98.6° F) pretransfusion to 37.2° C (99.0° F) B. Current blood pressure 178/90 mm Hg C. Heart rate change from 88/min pretransfusion to 120/min D. Client report of itching E. Client appears flushed
C. Heart rate change from 88/min pretransfusion to 120/min E. Client appears flushed -temp would increase 1°C -febrile reaction = hypotension -itching = allergic reaction ATI MS
type of tubing used for blood transfusions
Y-tubing
septicemia: nursing interventions (5)
-stop transfusion -keep line open with normal saline -obtain blood culture -obtain culture of blood bag -administer oxygen, antibiotics, etc.
A client has experienced high blood pressure and crackles in the lungs during previous blood transfusions. The client asks the nurse whether it is safe to receive another transfusion. The nurse explains that which medication most likely will be prescribed before the transfusion is begun? 1. Furosemide 2. Acetaminophen 3. Diphenhydramine 4. Acetylsalicylic acid
1. Furosemide (fluid overload is prevented by pretreating the client with a diuretic such as furosemide) NCLEX
5 types of transfusion reactions
1. hemolytic 2. febrile (nonhemolytic) 3. septicemia 4. fluid overload/circulatory overload 5. allergic/anaphylactic
Following infusion of a unit of PRBCs, the client has developed new onset of tachycardia, bounding pulses, crackles, and wheezes. Which action should the nurse implement first? 1. maintain bed rest with legs elevated 2. place the client in high-Fowler's position 3. increase the rate of infusion of IV fluids 4. consult with the health care provider regarding initiation of oxygen therapy
2. place the client in high-Fowler's position (symptoms = fluid overload - high-Fowler's will facilitate breathing) NCLEX
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? 1. An air vent 2. Tinted tubing 3. An in-line filter 4. A microdrip chamber
3. An in-line filter
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 records 100.6° F orally. Which action should the nurse take? 1. Begin the transfusion as prescribed. 2. Administer an antihistamine and begin the transfusion. 3. Delay hanging the blood and notify the health care provider (HCP). 4. Administer two tablets of acetaminophen (Tylenol) and begin the transfusion.
3. Delay hanging the blood and notify the health care provider (HCP). NCLEX
no more than ___ (time) can pass between taking the blood out of the refrigerator and starting the transfusion
30 min
The nurse enters the room of a client who began receiving a blood transfusion 45 minutes earlier to check on the client. The client is complaining of "itching all over" and has a generalized rash. The client's temperature has not changed from baseline and the lungs are clear to auscultation. Which complication of blood transfusion therapy should the nurse determine that this client is most likely experiencing? 1. Bacteremia 2. Fluid overload 3. Hypovolemic shock 4. Allergic transfusion reaction
4. Allergic transfusion reaction (pruritus = allergic reaction, sepsis = fever, fluid overload = lung crackles) NCLEX
A nurse is monitoring a client who is receiving a blood transfusion. After 30 minutes of the infusion, the client begins to have chills and back pain. His temperature is 100.1° F (37.8° C). What action should the nurse take first? 1. Assess the client for other symptoms. 2. Slow the blood transfusion and monitor the client's vital signs. 3. Remind the client that these are expected reactions to a blood transfusion. 4. Discontinue the infusion and start an infusion of normal saline using new tubing.
4. Discontinue the infusion and start an infusion of normal saline using new tubing. (back pain = hemolytic reaction)
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? 1. infusion pump 2. pulse oximeter 3. cardiac monitor 4. blood-warming device
4. blood-warming device -pulse oximetry and cardiac monitoring are useful for the early assessment of complications but do not reduce the occurrence of cardiac dysrhythmias -infusion pump is not helpful in this case because the infusion must be rapid and infusion devices are used to control the flow rate NCLEX
The initial nursing intervention for an acute hemolytic transfusion reaction would be to: a. slow the transfusion and call the health care provider b. stop the transfusion and turn the saline side of the administration set on at a slow keep open rate c. stop the transfusion, disconnect the tubing from the IV catheter, and initiate new saline and tubing to keep the vein open d. stop the transfusion and turn the saline side of the administration set on at a rapid rate
c. stop the transfusion, disconnect the tubing from the IV catheter, and initiate new saline and tubing to keep the vein open IV book
The nurse is preparing an infusion for a pt who has a deficiency in clotting factors. Which type of infusion is most appropriate? a. albumin 5% b. packed RBCs c. whole blood d. fresh frozen plasma
d. fresh frozen plasma Pharm text
which IV solutions are compatible with blood?
only 0.9% sodium chloride
indications for fresh frozen plasma (3)
used to provide clotting factors: -coagulation deficiencies (ex: hemophilia) -used for volume expansion (ex: trauma) -warfarin reversal
when would you use a blood warmer?
when rapid transfusion of PRBCs is required - transfusion of cold components can cause hypothermia and cardiac complications
A nurse has a prescription to transfuse a unit of packed red blood cells to a client who does not currently have an intravenous (IV) line inserted. When obtaining supplies to start the IV infusion, the nurse should select an angiocatheter of which size? 1. 19 gauge 2. 21 gauge 3. 22 gauge 4. 24 gauge
1. 19 gauge (18-20 gauge for blood transfusions) NCLEX
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 which time? 1. 1:30 2. 2:00 3. 2:30 4. 3:00
1. 1:30
The nurse has just received a prescription to transfuse a unit of PRBCs for an assigned client. Which action should the nurse take next? 1. check a set of vitals 2. order the blood from the blood bank 3. obtain Y-site blood administration tubing 4. check to be sure that consent for the transfusion has been signed
4. check to be sure that consent for the transfusion has been signed 1. consent 2. vitals 3. gather supplies 4. order blood from blood bank NCLEX
A nurse preceptor is observing a newly licensed nurse on the unit who is preparing to administer a blood transfusion to an older adult client. Which of the following actions by the newly licensed nurse indicates an understanding of the procedure? A. Inserts an 18‐gauge IV catheter in the client B. Verifies blood compatibility and expiration date of the blood with an assistive personnel (AP) C. Administers dextrose 5% in 0.9% sodium chloride IV with the transfusion D. Obtains vital signs every 15 min throughout the procedure.
D. Obtains vital signs every 15 min throughout the procedure. -don't use > 19-gauge for older pt -verify info with another RN not AP -no dextrose, only 0.9% NaCl ATI MS
Which action by the nurse is most appropriate for the pt receiving an infusion of PRBCs? a. flush the IV line with normal saline before the blood is added to the infusion b. flush the IV line with dextrose before the blood is added to the infusion c. check the pt's vital signs once the infusion is completed d. anticipate that flushed skin and fever are expected reactions to a blood transfusion
a. flush the IV line with normal saline before the blood is added to the infusion Pharm text
The universal recipient is a person with blood type: a. A-positive b. AB-positive c. O-negative d. AB-negative
b. AB-positive IV book
The nurse monitors for which signs of a possible transfusion reaction when a pt is receiving blood products? a. subnormal temperature and hypertension b. apprehension, restlessness, fever, and chills c. decreased pulse and respirations and fever d. headache, nausea, and lethargy
b. apprehension, restlessness, fever, and chills Pharm workbook
A nurse is preparing to transfuse a unit of PRBCs for a client who has severe anemia. Which of the following interventions will prevent an acute hemolytic reaction? a. ensuring that the client has a patent IV line before obtaining the blood product from the refrigerator b. obtain help from another nurse to confirm the correct client and blood product c. take a complete set of vital signs before beginning transfusion and periodically during the transfusion d. stay with the client for the first 15-30 min of the transfusion
b. obtain help from another nurse to confirm the correct client and blood product ATI Pharm
The nurse enters a client's room who began receiving a blood transfusion 45 minutes earlier to check on the client. The client is dyspneic and has a bounding pulse. The nurse listens to the client's lung sounds and notes the presence of crackles in the lung bases. Which complication of blood transfusion therapy should the nurse determine that this client is most likely experiencing? 1. Bacteremia 2. Fluid overload 3. Hypovolemic shock 4. Allergic transfusion reaction
2. Fluid overload
The nurse who is about to begin a blood transfusion knows that blood cells start to deteriorate after a certain period of time. The nurse takes which actions in order to prevent a complication of the blood transfusion as it relates to deterioration of blood cells? Select all that apply. 1. Checks the expiration date 2. Inspects for the presence of clots 3. Checks the blood group and type 4. Checks the blood identification number 5. Hangs the blood within the specified time frame per agency policy
1. Checks the expiration date 5. Hangs the blood within the specified time frame per agency policy NCLEX
The nurse is assisting in monitoring a client who is receiving a transfusion of packed red blood cells (PRBCs). Before leaving the room, the nurse tells the client to immediately report which symptoms of a transfusion reaction? (Select all that apply) 1. Chills 2. Fatigue 3. Sleepiness 4. Chest pain 5. Low back pain 6. Difficulty breathing
1. Chills 4. Chest pain 5. Low back pain 6. Difficulty breathing NCLEX
A client is brought to the emergency department having experienced blood loss related to an arterial laceration. Which blood component should the nurse expect the healthcare provider to prescribe? 1. platelets 2. granulocytes 3. fresh-frozen plasma 4. packed red blood cells
3. fresh-frozen plasma (used for fluid expansion as a result of fluid and blood loss) NCLEX
The nurse determines that a client is having a transfusion reaction. After the nurse stops the transfusion, which action should be taken next? 1. remove the intravenous line 2. run a solution of 5% dextrose in water 3. run normal saline at a keep-vein-open rate 4. obtain a culture of the tip of the catheter device removed from the client
3. run normal saline at a keep-vein-open rate (reaction = stop transfusion and infuse saline to maintain IV access and pt's intravascular volume) NCLEX
While receiving a unit of PRBCs, the pt develops chills and a temperature of 102.2°F (39°C). What is the priority action for the nurse to take? a. notify the health care provider and the blood bank b. recognize this as a mild allergic transfusion reaction and slow the transfusion c. stop the transfusion and instill normal saline d. add a leukocyte reduction filter to the blood administration set
c. stop the transfusion and instill normal saline MS workbook
A nurse is preparing to administer a transfusion of 300 mL of pool platelets to a client who has severe thrombocytopenia. The nurse should plan to administer the transfusion over which of the following time frames? a. within 30 min/unit b. within 60 min/unit c. within 2 hr/unit d. within 4 hr/unit
a. within 30 min/unit (platelets should be administered quickly to reduce the risk of clumping - within 15-30 min/unit) ATI Pharm
A client requiring surgery is anxious about the possible need for a blood transfusion during or after the procedure. The nurse suggests to the client to take which actions to reduce the risk of possible transfusion complications? Select all that apply. 1. Ask a family member to donate blood ahead of time. 2. Give an autologous blood donation before the surgery. 3. Take iron supplements before surgery to boost hemoglobin levels. 4. Request that any donated blood be screened twice by the blood bank. 5. Take adequate amounts of vitamin C several days prior to the surgery date.
1. Ask a family member to donate blood ahead of time. 2. Give an autologous blood donation before the surgery. NCLEX
The nurse has just obtained a unit of blood from the blood bank to transfuse into a client as prescribed. Before preparing the blood for transfusion, the nurse looks for which member of the health care team to assist in checking the unit of blood? 1. Phlebotomist 2. Medical student 3. Registered nurse (RN) 4. Blood bank technician
3. Registered nurse (RN) NCLEX
The nurse is caring for a client who is receiving a blood transfusion and is complaining of a cough. The nurse checks the client's vital signs, which include temperature of 97.2° F (36.2° C), pulse of 108 bpm, BP of 152/76, respiratory rate of 24 breaths/min, and an oxygen saturation level of 95% on room air. The client denies pain at this time. Based on this information, what initial action should the nurse take? 1. collect a urine sample for analysis 2. place the client in an upright position 3. compare current data to baseline data 4. slow the rate of the blood transfusion
3. compare current data to baseline data -symptoms indicate fluid overload, nurse should compare baseline data to current data and assess for other symptoms of fluid overload -if nurse still suspects this complication after comparing to baseline data, she should place pt in upright position and slow the rate of infusion NCLEX
A client has received a transfusion of platelets. The nurse evaluates that the client is benefiting most from this therapy if the client exhibits which finding? 1. Increased hematocrit level 2. Increased hemoglobin level 3. Decline of elevated temperature to normal 4. Decreased oozing of blood from puncture sites and gums
4. Decreased oozing of blood from puncture sites and gums NCLEX
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 department? 1. Blood bank 2. Infection control 3. Risk management 4. Environmental services
1. Blood bank NCLEX
A nurse is assessing a client during transfusion of a unit of whole blood. The client develops a cough, shortness of breath, elevated BP, and distended neck veins. The nurse should anticipate a prescription for which of the following medications? a. epinephrine b. lorazepam c. furosemide d. diphenhydramine
c. furosemide (symptoms = fluid overload) ATI Pharm
A nurse is transfusing a unit of PRBCs for a client who has anemia due to chemotherapy. The client reports a sudden headache and chills. The client's temperature is 2°F higher than her baseline. In addition to notifying the provider, which of the following actions should the nurse take? (Select all that apply) a. stop the transfusion b. place the client in an upright position with feet down c. remove the blood bag and tubing from the IV catheter d. obtain a urine specimen e. infuse dextrose 5% in water through the IV
a. stop the transfusion c. remove the blood bag and tubing from the IV catheter d. obtain a urine specimen (symptoms = hemolytic reaction - urine specimen to check for hemolysis is standard procedure) ATI Pharm
The nurse is told by a health care provider that a client in hypovolemic shock will require plasma expansion. The nurse anticipates receiving a prescription to transfuse which product? 1. Albumin 2. Platelets 3. Cryoprecipitate 4. Packed red blood cells
1. Albumin (albumin is used as a plasma expander) NCLEX
A unit of platelets was just received from the blood bank for transfusion to an assigned client. The nurse should select tubing with which feature for the transfusion? 1. an in-line filter 2. at least 3 Y-ports 3. self-sealing valves 4. tinted to protect blood from light
1. an in-line filter NCLEX
A client receiving a transfusion of packed red blood cells (PRBCs) begins to vomit. The client's blood pressure is 90/50 mm Hg from a baseline of 125/78 mm Hg. The client's temperature is 100.8° F orally from a baseline of 99.2° F orally. The nurse determines that the client may be experiencing which complication of a blood transfusion? 1. Septicemia 2. Hyperkalemia 3. Circulatory overload 4. Delayed transfusion reaction
1. Septicemia (septicemia symptoms: vomiting, hypotension, fever) NCLEX
acute hemolytic reaction: nursing interventions (5)
1. stop transfusion 2. change IV tubing 3. keep line open with normal saline 4. notify HCP 5. return blood bag and tubing to blood bank
