CH 32 Assessment of Hematologic Function and Treatment Modalities (E1)
A nurse at a blood donation clinic has completed the collection of blood from a woman. The woman states that she feels "lightheaded" and she appears visibly pale. What is the nurse's most appropriate action? A) Help her into a sitting position with her head lowered below her knees. B) Administer supplementary oxygen by nasal prongs. C) Obtain a full set of vital signs. D) Inform a physician or other primary care provider.
A
A patient is receiving a blood transfusion and complains of a new onset of slight dyspnea. The nurse's rapid assessment reveals bilateral lung crackles and elevated BP. What is the nurse's most appropriate action? A) Slow the infusion rate and monitor the patient closely. B) Discontinue the transfusion and begin resuscitation. C) Pause the transfusion and administer a 250 mL bolus of normal saline. D) Discontinue the transfusion and administer a beta-blocker, as ordered.
A
The nurse is preparing to administer a unit of platelets to an adult patient. When administering this blood product, which of the following actions should the nurse perform? A) Administer the platelets as rapidly as the patient can tolerate. B) Establish IV access as soon as the platelets arrive from the blood bank. C) Ensure that the patient has a patent central venous catheter. D) Aspirate 10 to 15 mL of blood from the patient's IV immediately following the transfusion
A
A nurse is caring for a client who is receiving a blood transfusion. Which of the following actions should the nurse plan to take if an allergic transfusion reaction is expected? 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 upright with feet lower than the heart. E) Administer diphenhydramine.
A, C, E
A nurse has participated in organizing a blood donation drive at a local community center. Which of the following individuals would most likely be disallowed from donating blood? A) A man who is 81 years of age B) A woman whose blood pressure is 88/51 mm Hg C) A man who donated blood 4 months ago D) A woman who has type 1 diabetes
B
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 minutes of the transfusion? A) Obtain consent from the client for the transfusion. B) Assess for acute hemolytic reaction. C) Explain the transfusion procedure to the client. D) Obtain blood culture specimens to send to the lab.
B
A patient is being treated in the ICU after a medical error resulted in an acute hemolytic transfusion reaction. What was the etiology of this patient's adverse reaction? A) Antibodies to donor leukocytes remained in the blood. B) The donor blood was incompatible with that of the patient. C) The patient had a sensitivity reaction to a plasma protein in the blood. D) The blood was infused too quickly and overwhelmed the patient's circulatory system.
B
A patient is receiving the first of two ordered units of PRBCs. Shortly after the initiation of the transfusion, the patient complains of chills and experiences a sharp increase in temperature. What is the nurse's priority action? A) Position the patient in high Fowler's. B) Discontinue the transfusion. C) Auscultate the patient's lungs. D) Obtain a blood specimen from the patient.
B
A patient on the medical unit is receiving a unit of PRBCs. Difficult IV access has necessitated a slow infusion rate and the nurse notes that the infusion began 4 hours ago. What is the nurse's most appropriate action? A) Apply an icepack to the blood that remains to be infused. B) Discontinue the remainder of the PRBC transfusion and inform the physician. C) Disconnect the bag of PRBCs, cool for 30 minutes and then administer. D) Administer the remaining PRBCs by the IV direct (IV push) route.
B
A patient undergoing a hip replacement has autologous blood on standby if a transfusion is needed. What is the primary advantage of autologous transfusions? A) Safe transfusion for patients with a history of transfusion reactions B) Prevention of viral infections from another person's blood C) Avoidance of complications in patients with alloantibodies D) Prevention of alloimmunization
B
The nurse caring for a patient receiving a transfusion notes that 15 minutes after the infusion of packed red blood cells (PRBCs) has begun, the patient is having difficulty breathing and complains of severe chest tightness. What is the most appropriate initial action for the nurse to take? A) Notify the patient's physician. B) Stop the transfusion immediately. C) Remove the patient's IV access. D) Assess the patient's chest sounds and vital signs.
B
A nurse is providing preoperative teaching for a client who requests autologous donation in preparation for a scheduled orthopedic 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 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
A patient's low hemoglobin level has necessitated transfusion of PRBCs. Prior to administration, what action should the nurse perform? A) Have the patient identify his or her blood type in writing. B) Ensure that the patient has granted verbal consent for transfusion. C) Assess the patient's vital signs to establish baselines. D) Facilitate insertion of a central venous catheter.
C
Fresh-frozen plasma (FFP) has been ordered for a hospital patient. Prior to administration of this blood product, the nurse should prioritize what patient education? A) Infection risks associated with FFP administration B) Physiologic functions of plasma C) Signs and symptoms of a transfusion reaction D) Strategies for managing transfusion-associated anxiety
C
Which of the following circumstances would most clearly warrant autologous blood donation? A) The patient has type-O blood. B) The patient has sickle cell disease or a thalassemia. C) The patient has elective surgery pending. D) The patient has hepatitis C.
C
A nurse is monitoring a client who began receiving a unit of packed RBCs 10 minutes 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 98.6 pretransfusion to 99.0 B) Current blood pressure 178/90 mmHg C) Heart rate change from 88/min pretransfusion to 120/min D) Client report of itching E) Client appears flushed
C, E
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 catheter in the client B) Verifies blood compatibility and expiration date of the blood with as assistive personnel C) Administers dextrose 5% in 0.9% sodium chloride IV with the transfusion D) Obtains vital signs every 15 minutes throughout the procedure
D
An interdisciplinary team has been commissioned to create policies and procedures aimed at preventing acute hemolytic transfusion reactions. What action has the greatest potential to reduce the risk of this transfusion reaction? A) Ensure that blood components are never infused at a rate greater than 125 mL/hr. B) Administer prophylactic antihistamines prior to all blood transfusions. C) Establish baseline vital signs for all patients receiving transfusions. D) Be vigilant in identifying the patient and the blood component.
D
Two units of PRBCs have been ordered for a patient who has experienced a GI bleed. The patient is highly reluctant to receive a transfusion, stating, "I'm terrified of getting AIDS from a blood transfusion." How can the nurse best address the patient's concerns? A) All the donated blood in the United States is treated with antiretroviral medications before it is used. B) That did happen in some high-profile cases in the twentieth century, but it is no longer a possibility. C) HIV was eradicated from the US blood supply in the early 2000s. D) The chances of contracting AIDS from a blood transfusion in the United States are exceedingly low.
D