Chapter 32

Delayed hemolytic reactions usually occur within _________ days after transfusion, when the level of antibody has been increased to the extent that a reaction can occur.

14

A client receiving a blood transfusion reports shortness of breath, appears anxious, and has a pulse of 125 beats/minute. What is the best action for the nurse to take after stopping the transfusion and awaiting further instruction from the health care provider?

Ensure there is an oxygen delivery device at the bedside.

A client with severe anemia is admitted to the hospital. Because of religious beliefs, the client is refusing blood transfusions. The nurse anticipates pharmacologic therapy with which drug to stimulate the production of red blood cells?

Epoetin alfa

A client with chronic kidney disease has chronic anemia. What pharmacologic alternative to blood transfusion may be used for this client?

Erythropoietin

T or F- The average lifespan of a normal circulating erythrocyte is 60 days or about 2 months.

False

A patient who has long-term packed RBC (PRBC) transfusions has developed symptoms of iron toxicity that affect liver function. What immediate treatment should the nurse anticipate preparing the patient for that can help prevent organ damage?

Iron chelation therapy

The nurse is providing health education to an older adult client who has low red blood cell levels. To promote red blood cell production, the nurse should encourage intake of what foods? Select all that apply.

Leafy green vegetables Nuts and seeds Lean meats

A nurse cares for a client who has had a bone marrow aspiration. In addition to the client's aspiration site, what locations on the body does the nurse recognize as having bone marrow? Select all that apply.

Pelvis, Ribs, Vertebrae, Sternum

The client is planned to have a splenectomy. The nurse should prepare which medication to administer to this client?

Pneumococcal vaccine

A nurse cares for several mothers and babies in the postpartum unit. Which mother does the nurse recognize as being most at risk for a febrile nonhemolytic reaction?

Rh-negative mother; Rh-positive child

Place the following procedural steps in order for transfusing a unit of packed red blood cells (PRBCs).

Start an intravenous line. Obtain the unit of PRBCs from the blood bank. Double check the labels with another nurse to ensure correct ABO group and Rh type. Initiate the blood transfusion within 30 minutes of receipt. Monitor closely for signs of a transfusion reaction.

Which type of lymphocyte is responsible for cellular immunity?

T lymphocytes

The nurse is administering a blood transfusion to a client over 4 hours. After 2 hours, the client reports chills and has a fever of 101°F, an increase from a previous temperature of 99.2°F. What does the nurse recognize is occurring with this client?

The client is having a febrile nonhemolytic reaction.

A nurse is assigned to care for a patient with ascites, secondary to cirrhosis. The nurse understands that the fluid accumulation in the peritoneal cavity results from a combination of factors including an alteration in oncotic pressure gradients and increased capillary permeability. Therefore, the nurse monitors the serum level of the plasma protein responsible for maintaining oncotic pressure, which is:

albumin

Plasma proteins consist primarily of __________ and globulins.

albumin

An increase in _______________ may be seen in patients exposed to a bacterial infection.

neutrophils

Patients who have had a partial or total gastrectomy may have limited amounts of intrinsic factor, therefore the absorption of vitamin _______ may be diminished.

B12

The nurse expects which assessment finding of the oral cavity when the client is diagnosed with pernicious anemia?

smooth tounge

A patient will need a blood transfusion for the replacement of blood loss from the gastrointestinal tract. The patient states, "That stuff isn't safe!" What is the best response from the nurse?

"I understand your concern. The blood is carefully screened but is not completely risk free."

A nurse cares for a client with megaloblastic anemia who had a total gastrectomy three years ago. What statement will the nurse include in the client's teaching regarding the condition?

"The condition is likely caused by a vitamin B12 deficiency."

A nurse is caring for a client who will undergo total knee replacement and will have an autologous transfusion. Which statement will the nurse include when teaching the client about the transfusion?

"You typically donate blood 4 to 6 weeks before the surgery."

A client with a history of congestive heart failure has an order to receive 1 unit of packed red blood cells (RBCs). If the nurse hangs the blood at 12:00 pm, by what time must the infusion be completed?

4 pm

A nurse is preparing a dose of furosemide for an older adult with heart failure. The health care provider orders furosemide 1 mg/kg to be given intravenously. The client weighs 50 kg. The concentration of the drug is 40 mg/4mL (10 mg/mL). How many milliliters would the nurse administer? Record your answer using a whole number.

5

A client with Hodgkin disease had a bone marrow biopsy yesterday and reports aching at the biopsy site, rated a 5 (on a 1-10 scale). After assessing the biopsy site, which nursing intervention is most appropriate?

Administer acetaminophen 500 mg po, as ordered

____________ is the primary site for hematopoiesis, a process of continuous blood cell formation.

Bone Marrow

A nursing instructor in a BSN program is preparing for a lecture on disorders of the hematopoietic system. Included in the lecture are conditions caused by reduced levels or absence of blood-clotting proteins. Which of the following is the instructor most likely referring to?

Coagulopathy

The nurse is instructing the client with polycythemia vera how to perform isometric exercises such as contracting and relaxing the quadriceps and gluteal muscle during periods of inactivity. What does the nurse understand is the rationale for this type of exercise?

Contraction of skeletal muscle compresses the walls of veins and increases the circulation of venous blood as it returns to the heart.

The nurse should be alert to which adverse assessment finding when transfusing a unit of packed red blood cells (PRBCs) too rapidly?

Crackles auscultated bilaterally

A client receiving a unit of packed red blood cells (PRBCs) has been prescribed morphine 1 mg intravenously now for pain. What is the best method for the nurse to administer the morphine?

Disconnect the blood tubing, flush with normal saline, and administer morphine.

A patient is undergoing platelet pheresis at the outpatient clinic. What does the nurse know is the most likely clinical disorder the patient is being treated for?

Essential thrombocythemia

When conducting a health assessment on a client suspected for having a hematological disorder, the nurse should collect which data? Select all that apply.

Ethnicity Medication use Herbal supplements Dietary intake

T or F- The most common type of blood transfusion reaction is an allergic reaction that causes urticaria.

False

T or F- To be considered a blood donor, a man must have a minimum hemoglobin level of 12 g/dL.

False

A nurse is caring for a patient who has had a bone marrow aspiration with biopsy. What complication should the nurse be aware of and monitor the patient for?

Hemorrhage

When teaching about the advantages of autologous blood transfusion to a client, the nurse should include which information? Select all that apply.

It is safer for clients with a history of transfusion reactions. If not needed immediately, the blood can be frozen for future use. The primary advantage is prevention of viral infections.

A client in acute renal failure has been prescribed 2 units of packed red blood cells (PRBCs). The nurse explains to the client that the blood transfusion is most likely needed for which reason?

Lack of erythropoietin

The nurse is preparing a patient for a bone marrow aspiration and biopsy from the site of the posterior superior iliac crest. What position will the nurse place the patient in?

Lateral position with one leg flexed

Which blood cell type is matched correctly with its function?

Leukocyte: Fights infection

Which term refers to a form of white blood cell involved in immune response?

Lymphocyte

Which cell of hematopoiesis is responsible for the production of red blood cells (RBCs) and platelets?

Myeloid stem cell

A client involved in a motor vehicle accident arrives at the emergency department unconscious and severely hypotensive. The nurse suspects the client has several fractures in the pelvis and legs. Which parenteral fluid is the best choice for the client's current condition?

Packed red blood cells (RBCs)

An older adult client presents to the health care provider's office and reports exhaustion. The nurse, aware of the most common hematologic condition affecting the elderly, knows that which laboratory values should be assessed?

RBC count

Place the following steps in order when determining the type and severity of a transfusion reaction. Use all options.

Stop the transfusion. Assess the client. Notify the health care provider. Notify the blood bank. Send the tubing and container to the blood bank.

A nurse is caring for a client with a diagnosis of lymphocytopenia. Which assessment finding will the nurse consider most concerning when caring for this client?

Temperature of 37.7 degrees Celsius

The nurse is caring for a client with hypoxia. What does the nurse understand is true regarding the client's oxygen level and the production of red blood cells?

The kidneys sense low oxygen levels in the blood and stimulate erythropoietin, stimulating the marrow to produce more red blood cells.

T or F- The patient, who is experiencing severe circulatory overload due to too much blood infusing too quickly, should be placed in an upright position with the feet in a dependent position.

True

T or F- The primary function of lymphocytes is to attack foreign material.

True

While caring for a client, the nurse notes petechiae on the client's trunk and lower extremities. What precaution will the nurse take when caring for this client?

Use an electric razor when assisting client with shaving.

A client comes into the emergency department reporting an enlarged tongue. The tongue appears smooth and beefy red in color. The nurse also observes a 5-cm incision on the upper left quadrant of the abdomen. When questioned, the client states, "I had a partial gastrostomy 2 years ago." Based on this information, the nurse attributes these symptoms to which problem?

Vitamin B12 deficiency

The body responds to infection by increasing the production of white blood cells (WBCs). The nurse should evaluate the differential count for what type of WBCs, which are the first WBCs to respond to an inflammatory event?

neutrophils

A nurse is transfusing whole blood to a client with impaired renal function. During the transfusion, the client tells the nurse, "I feel very short of breath all of a sudden." What is the nurse's primary action?

stop the infusion