Chapter #32
A patient with a history of congestive heart failure has an order to receive one 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?
4:00 pm
A female patient has a hemoglobin of 6.4 g/dL and is preparing to have a blood transfusion. Why would it be important for the nurse to obtain information about the patient's history of pregnancy prior to the transfusion?
A high number of pregnancies can increase the risk of reaction. Explanation: The patient history is an important component of the pretransfusion assessment to determine the history of previous transfusions as well as previous reactions to transfusion. The history should include the type of reaction, its manifestations, the interventions required, and whether any preventive interventions were used in subsequent transfusions. The nurse assesses the number of pregnancies a woman has had, because a high number can increase her risk of reaction due to antibodies developed from exposure to fetal circulation.
Which client is not a candidate for blood donation according to the American Heart Association?
Clients must meet the following criteria to be eligible as blood donors: body weight at least 50 kg; pulse rate regular between 50 and 100 bpm; systolic BP 90 to 180 mmHg and diastolic 50 to 100 mmHg; hemoglobin level at least 12.5 g/dL for women. There is no upper age limit to donation.
The client is a young, thin woman who is prescribed iron dextran intramuscularly. The nurse, when administering the medication
Employs the Z-track technique Explanation: When iron medications are given intramuscularly, the nurse uses the Z-track technique to avoid local pain and staining of the skin. The gluteus maximus muscle is used. The nurse avoids rubbing the site vigorously and uses a 189- or 20-gauge needle.
A client complains of feeling faint after donating blood. What is the nurse's best action? You Selected:
Keep client in recumbent position to rest. Explanation: After blood donation, the donor should remain recumbent until he or she feels able to sit up. Donors who experience weakness or faintness should rest for a longer period. High-Fowler's position would not promote blood flow to the brain, and could cause the client to feel light-headed or faint. Ambulating a client who feels faint is not safe due to the high risk of falling. Trendelenburg position is not recommended after blood donation.
The nurse obtains a unit of blood for the client, Donald D. Smith. The name on the label on the unit of blood reads Donald A. Smith. All the other identifiers are correct. The nurse
Refuses to administer the blood Explanation: To ensure a safe transfusion, all components of the identification must be correct. The nurse should refuse to administer the blood and notify the Blood Bank about the discrepancy. The Blook Bank should then take the necessary steps to correct the name on the label on the unit of blood.
The nurse is working at a blood donation clinic. What teaching should the nurse provide to the donor immediately after blood donation?
Remain for observation after eating and drinking. Explanation: After blood donation, the donor receives food and fluids and is asked to remain for observation. After the needle is removed, donors are asked to hold the involved arm straight up, and firm pressure is applied with sterile gauze for 2 to 3 minutes. A firm bandage is then applied. The donor remains recumbent until he or she feels able to sit up, usually within a few minutes.
A client with a history of sickle cell anemia has developed iron overload from repeated blood transfusions. What treatment does the nurse anticipate will be prescribed?
Chelation therapy is prescribed to treat iron overload. Hepatitis B immunization helps immunize against hepatitis B. Red blood cell phenotyping helps decreased sensitization. A white blood cell filter protects against cytomegalovirus and some sensitization and febrile reactions.
The client is planned to have a splenectomy. The nurse should prepare which medication to administer to this client?
Pneumococcal vaccine Explanation: Without a spleen, the client's risk of infection is greatly increased. The pneumococcal vaccine should be administered, preferable before splenectomy. Aspirin should not be administered due to the increased risk of bleeding. IgG is administered to client with increased chance of bacterial infections but is not routinely given to client undergoing splenectomy, as is the pneumococcal vaccine. Factor VII is given to treat bleeding disorders.
The nurse is completing a pretransfusion assessment to determine the history of previous transfusions as well as previous reactions to transfusions for a female patient. From the following list, what is the most important information to obtain from this patient prior to the transfusion?
Number of pregnancies Explanation: The history should include the type of reaction, its manifestations, the interventions required, and whether any preventive interventions were used in subsequent transfusions. The nurse assesses the number of pregnancies a woman has had because a high number can increase her risk of reaction due to antibodies developed from exposure to fetal circulation. Other concurrent health problems should be noted, with careful attention paid to cardiac, pulmonary, and vascular disease.
A patient develops a hemolytic reaction to a blood transfusion. What actions should the nurse take after this occurs? (Select all that apply.)
Obtain appropriate blood specimens. Collect a urine sample to detect hemoglobin. Document the reaction according to policy. Explanation: If a hemolytic transfusion reaction or bacterial infection is suspected, the nurse does the following: obtains appropriate blood specimens from the patient; collects a urine sample as soon as possible to detect hemoglobin in the urine; and documents the reaction according to the institution's policy.
A patient receiving plasma develops transfusion-related acute lung injury (TRALI) 4 hours after the transfusion. What type of aggressive therapy does the nurse anticipate the patient will receive to prevent death from the injury? (Select all that apply.)
Oxygen Fluid support Intubation and mechanical ventilation Explanation: Transfusion-related acute lung injury (TRALI) is a potentially fatal, idiosyncratic reaction that is defined as the development of acute lung injury occurring within 6 hours after a blood transfusion. Aggressive supportive therapy (e.g., oxygen, intubation, fluid support) may prevent death.
A client involved in a motor vehicle accident arrives at the emergency department unconscious and severely hypotensive. The nurse suspects he 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) Explanation: In a trauma situation, the first blood product given is unmatched (O negative) packed RBCs. Fresh frozen plasma is commonly used to replace clotting factors. Normal saline or lactated Ringer's solution is used to increase volume and blood pressure; however, too much colloid will hemodilute the blood and doesn't improve oxygen-carrying capacity as well as packed RBCs do.
The nurse reviewing laboratory results of a client recovering from abdominal surgery notices an elevated number of reticulocytes. What is the nurse's first action?
Perform an abdominal assessment. Explanation: The bone marrow can release immature forms of erythrocytes, called reticulocytes, into the circulation in response to bleeding. The nurse should assess this client's abdomen, because the client is recovering from abdominal surgery. The nurse should assess and gather more data before notifying the healthcare provider. A blood transfusion would not be held if internal bleeding is expected.
Discontinue the infusion immediately and maintain the IV line with normal saline solution using new IV tubing Explanation: The following steps are taken to determine the type and severity of the reaction: Stop the transfusion. Maintain the IV line with normal saline solution through new IV tubing, administered at a slow rate. Assess the patient carefully. Notify the physician. Continue to monitor the patient's vital signs and respiratory, cardiovascular, and renal status. Notify the blood bank that a suspected transfusion reaction has occurred and send the blood container and tubing to the blood bank for repeat typing and culture.
Administer eltrombopag (Promacta) Explanation: Thrombopoietin (TPO) is a cytokine that is necessary for the proliferation of megakaryocytes and subsequent platelet formation. Nonimmunogenic second-generation thrombopoietic growth factors (romiplastin [Nplate] and eltrombopag [Promacta]) were recently approved for the treatment of idiopathic thrombocytopenia purpura.
A patient with Hodgkin's disease had a bone marrow biopsy yesterday and is complaining of aching, rated at a 5 (on a 1-10 scale), at the biopsy site. After assessing the biopsy site, which of the following nursing interventions is most appropriate?
Administer the ordered paracetamol 500 mg po Explanation: After the marrow sample is obtained, pressure is applied to the site for several minutes. The site is then covered with a sterile dressing. Most patients have no discomfort after a bone marrow aspiration, but the site of a biopsy may ache for 1 or 2 days. Warm tub baths and a mild analgesic agent (e.g., paracetamol) may be useful. Aspirin-containing analgesic agents should be avoided it the immediate post-procedure period because they can aggravate or potentiate bleeding.
The nurse begins a routine blood transfusion of packed red blood cells (PRBCs) at 1100. To ensure client safety, the unit of blood should be completely transfused by what time?
Administration time for PRBCs should not exceed 4 hours because of the increased risk of bacterial proliferation. For the first 15 minutes, the transfusion should be run slowly- no faster than 5 mL/min.
A 67-year-old client at the free clinic where you practice nursing has a history of seizures and presents with severe fatigue, frequent headaches, and a sore and beefy red tongue. Which of the following could be causing her current condition? Select all that apply.
Alcoholism Intestinal disorders Older adults and clients with alcoholism, intestinal disorders that affect food absorption, malignant disorders, and chronic illnesses often have a folic acid deficiency because of poor nutrition.
The client is to receive a unit of packed red blood cells. The first intervention of the nurse is to You Selected: Verify that the client has signed a written consent form.
All the options are interventions the nurse will do to ensure the blood transfusion is safe. The question asks about the first action of the nurse. The first action would be verifying that the client has signed a written consent form. Then, the nurse would ensure the intravenous site has a 20-gauge or larger needle. The nurse would proceed to obtain the unit of blood, check the blood with another registered nurse, and observe for gas bubbles in the unit of blood.
A client in end-stage renal disease is prescribed epoetin alfa (Epogen) and oral iron supplements. Before administering the next dose of epoetin alfa and oral iron supplement, the nurse
Assesses the hemoglobin level Explanation: Erythropoietin with oral iron supplements can raise hematocrit levels in the client with end-stage renal disease. The nurse should check the hemoglobin prior to administration of erythropoietin, because too high a hemoglobin level can put the client at risk for heart failure, myocardial infarction, and cerebrovascular accident. Erythropoietin may be administered during dialysis treatments. The BUN will be elevated in the client with end-stage renal disease.
The nurse recognizes the most common cause of iron deficiency anemia in an adult is which of the following?
Bleeding Explanation: Iron deficiency in the adult generally indicates blood loss (e.g., from bleeding in the GI tract or heavy menstrual flow). Lack of dietary iron is rarely the sole cause of iron deficiency anemia in adults. The source of iron deficiency should be investigated promptly, because iron deficiency in an adult may be a sign of bleeding in the GI tract or colon cancer.
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. Explanation: Isometric exercise induce contraction of skeletal muscle so that it compresses the walls of veins and increases the circulation of venous blood as it returns to the heart. Isometric exercises do not have an aerobic effect and should not increase the heart rate; although, it may increase blood pressure. Isometric exercise does not decrease the workload of the heart. Arterial flow moves blood flow away from the heart after being oxygenated.
During a blood transfusion with packed red blood cells (RBCs), a patient begins to complain of chills, low back pain, and nausea. What priority action should the nurse take?
Discontinue the infusion immediately and maintain the IV line with normal saline solution using new IV tubing Explanation: The following steps are taken to determine the type and severity of the reaction: Stop the transfusion. Maintain the IV line with normal saline solution through new IV tubing, administered at a slow rate. Assess the patient carefully. Notify the physician. Continue to monitor the patient's vital signs and respiratory, cardiovascular, and renal status. Notify the blood bank that a suspected transfusion reaction has occurred and send the blood container and tubing to the blood bank for repeat typing and culture.
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 Explanation: Hazards of either bone marrow aspiration or biopsy include bleeding and infection. The risk of bleeding is somewhat increased if the patient's platelet count is low or if the patient has been taking a medication (e.g., aspirin) that alters platelet function.
A client is prescribed an intravenous dose of iron dextran. The nurse
Ensures that epinephrine is available Explanation: When iron is given intravenously, the nurse should have emergency medications, such as epinephrine, available in case of anaphylaxis. Acute hypersensitivity reactions during iron infusions are very rare but can be life-threatening. Iron preparations will not cause a false-positive on stool analysis for occult blood. One dose of iron will not reverse iron-deficiency anemia; in fact, several doses of iron are required to replenish the client's deficient iron stores. The client's hemoglobin levels may increase in a few weeks.
A patient with severe anemia is admitted to the hospital. Due to religious beliefs, the patient is refusing blood transfusions. The nurse anticipates drug therapy with which drug to stimulate the production of red blood cells?
Epoetin alfa (Epogen) Explanation: Erythropoietin (epoetin alfa [Epogen, Procrit]) is an effective alternative treatment for patients with chronic anemia secondary to diminished levels of erythropoietin. This medication stimulates erythropoiesis.
A client tells the nurse that he would like to donate blood before his abdominal surgery next week. What should be the nurse's first action?
Explain the time frame needed for autologous donation. Explanation: Preoperative autologous donations are ideally collected 4 to 6 weeks before surgery. The nurse should first explain that time frame to this client. Surgery is scheduled in one week which means that autologous blood donation may not be an option for this client. A list of donation centers can be provided to the client; and even though iron is recommended and 2 units of blood may be suggested, the first action is to tell the client about the needed time frame for donation.
The nurse caring for a client with acute liver failure should expect which assessment finding?
Generalized edema Explanation: People with impaired hepatic function may have low concentrations of albumin, with a resultant decreased in osmotic pressure and the development of edema. Albumin is produced by the liver; the level would be decreased, not increased in liver failure. Albumin is important to maintain fluid balance in the vascular system. Its presence in plasma keeps fluid in the vascular space. With impaired hepatic function and low levels of albumin, the client is more likely to suffer hypotension and tachycardia as a result of hypovolemia.
Splenic sequestration is diagnosed in a client admitted with splenomegaly. What is the priority of care for this client?
Hypovolemia Explanation: If the spleen is enlarged, a greater proportion of red cells and platelets can be sequestered. With less red blood cells in circulation, the client can become hypovolemic resulting in shock. Decreased white blood cells in circulation, not red blood cells, increases the chance of infection. Decreased circulatory volume results in hypotension, not hypertension. Hyperthermia is not a result of decreased red blood cells in circulation.
A client is receiving platelets. In order to decreased the risk of circulatory overload in this client, the nurse should do which of the following?
Infuse each unit over 30-60 minutes per client tolerance. Explanation: Infuse each unit of FFP over 30-60 minutes per client tolerance. Platelet clumping will occur if administered too slowly. Vital signs should be monitored before and throughout the transfusion, not just once per shift. A liter of saline is too large an amount to flush the intravenous line and would contribute to fluid overload.
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 Explanation: Iron overload is a complication unique to people who have had long-term PRBC transfusions. One unit of PRBCs contains 250 mg of iron. Patients with chronic transfusion requirements can quickly acquire more iron than they can use, leading to iron overload. Over time, the excess iron deposits in body tissues and can cause organ damage, particularly in the liver, heart, testes, and pancreas. Promptly initiating a program of iron chelation therapy can prevent end-organ damage from iron toxicity.
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 Explanation: Bone marrow aspiration procedure. The posterior superior iliac crest is the preferred site for bone marrow aspiration and biopsy because no vital organs or vessels are nearby. The patient is placed either in the lateral position with one leg flexed or in the prone position.
Albumin is important for the maintenance of fluid balance within the vascular system. Albumin is produced by which of the following?
Liver Explanation: Albumin is produced by the liver.
One hour after a transfusion of packed red cells is started; a patient develops redness on his trunk and complains of itching. The nurse stops the red blood cell (RBC) infusion and administers the ordered diphenhydramine (Benadryl) 25 mg po. Thirty minutes later, the redness and itching is gone. What is the next action the nurse should take?
Resume the transfusion Explanation: Some patients develop urticaria (hives) or generalized itching during a transfusion. The cause of these reactions is thought to be a sensitivity reaction to a plasma protein within the blood component being transfused. Symptoms of an allergic reaction are urticaria, itching, and flushing. The reactions are usually mild and respond to antihistamines. If the symptoms resolve after administration of an antihistamine (e.g., diphenhydramine [Benadryl]), the transfusion may be resumed.
A nurse practitioner reviewed the blood work of a male patient suspected of having microcytic anemia. The nurse suspected occult bleeding. Identify the laboratory result that would indicate this initial stage of iron deficiency.
Serum ferritin: 15 ng/mL Microcytic anemia is characterized by small RBCs due to insufficient hemoglobin. Serum ferritin levels correlate to iron deficiency and decrease as an initial response to anemia before hemoglobin and serum iron levels drop.
A nurse, caring for a patient with human immunodeficiency virus (HIV), reviews the patient's differential WBC count to check the level of which of the following?
T lymphocytes Explanation: Lymphocytes (T cells, B cells, and natural killer cells) are WBCs that are the major components of the body's immune response. T cells are primarily responsible for cell-mediated immunity, whereas B cells are involved in antibody production.
Which type of lymphocyte is responsible for cellular immunity?
T lymphocytes are responsible for delayed allergic reactions, rejection of foreign tissue (e.g., transplanted organs), and destruction of tumor cells. This process is known as cellular immunity. B lymphocytes are responsible for humoral immunity. A plasma cell secretes immunoglobulin. A basophil contains histamine and is an integral part of hypersensivity reactions.
The nurse is administering a blood transfusion to a patient over 4 hours. After 2 hours, the patient complaints of 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 patient?
The patient is having a febrile nonhemolytic reaction. Explanation: The signs and symptoms of a febrile nonhemolytic transfusion reaction are chills (minimal to severe) followed by fever (more than 1°C elevation). The fever typically begins within 2 hours after the transfusion is begun. Although the reaction is not life threatening, the fever, and particularly the chills and muscle stiffness, can be frightening to the patient.
A patient comes into the emergency room with complaints of 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 patient states, "I had a partial gastrostomy 2 years ago." Based on this information, the nurse attributes these symptoms to which of the following problems?
Vitamin B12 deficiency Explanation: Because vitamin B12 is found only in foods of animal origin, strict vegetarians may ingest little vitamin B12. Vitamin B12 combines with intrinsic factor produced in the stomach. The vitamin B12-intrinsic factor complex is absorbed in the distal ileum. People who have had a partial or total gastrectomy may have limited amounts of intrinsic factor, and therefore the absorption of vitamin B12 may be diminished. The effects of either decreased absorption or decreased intake of vitamin B12 are not apparent for 2-4 years. This results in megaloblastic anemia. Some symptoms are smooth, beefy red, enlarged tongue and cranial nerve deficiencies.
An 84-year-old woman is to receive 2 units of packed red blood cells. During the transfusion of the first unit at 125 mL/hour, the client reports shortness of breath 30 minutes into the process. The client exhibits the vital signs shown in the accompanying table. The best nursing intervention is to:
slow the rate of the transfusion and obtain an order for furosemide (Lasix) The description is consistent with a client who is experiencing circulatory overload. The nurse is to slow the rate of the transfusion and administer a diuretic. Oxygen is administered with a prescription and for severe dyspnea. This option does not allow for the nurse to slow the transfusion. The nurse would still be administering the blood at the current rate of 125 mL/hour. Diphenhydramine would be prescribed for an allergic reaction. Blood and urine specimens are obtained for acute hemolytic reactions.