MedSurgII-Exam1
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? Lactated Ringer's 0.9% sodium chloride 5% dextrose in 0.9% sodium chloride 5% dextrose in 0.45% sodium chloride
0.9% sodium chloride Rationale: Sodium chloride 0.9% (normal saline) is a standard isotonic solution used to precede and follow infusion of blood products. Dextrose is not used because it could result in clumping and subsequent hemolysis of red blood cells (RBCs). Lactated Ringer's is not the solution of choice with this procedure.
Most critical phase of transfusion is?
Confirming product compatibility and verifying client identity
True or false: Two licensed nurses need to check the PHCP's prescription, client identity and client ID band and number ,verifying the name and number are identical to those on the blood component tag?
True
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? a. "Have you ever had a transfusion before?" b. "Why do you think that you need the transfusion?" c. "Have you ever gone into shock for any reason in the past?" d. "Do you know the complications and risks of a transfusion?"
a. Have you ever had a transfusion before? Rationale: Asking the client about personal experience with transfusion therapy provides a good starting point for client teaching about this procedure. Questioning about previous history of shock and knowledge of complications and risks of transfusion is not helpful because it may elicit a fearful response from the client. Although determining whether the client knows the reason for the transfusion is important, it is not an appropriate statement in terms of eliciting information from the client regarding an understanding of the need for the transfusion.
What do you do if a transfusion reaction occurs? (priority nursing actions)
Stop the transfusion! Change the IV tubing down to the IV site. Keep the IV line open with normal saline. Notify the PHCP and blood bank. Stay with your patient and monitor vital signs and any life threatening s/s Return the blood bag, attached labels, tubing and records to the blood bank. Document the occurrence, actions taken, and client's response.
Packed red blood cells have been prescribed for a female client with a hemoglobin level of 7.6 g/dL (76 mmol/L) and a hematocrit level of 30% (0.30). The nurse takes the client's temperature before hanging the blood transfusion and records 100.6º F (38.1º C) orally. Which action should the nurse take? Begin the transfusion as prescribed. Administer an antihistamine and begin the transfusion. Administer 2 tablets of acetaminophen and begin the transfusion. Delay hanging the blood and notify the primary health care provider (PHCP).
Delay hanging the blood and notify the primary health care provider (PHCP). If the client has a temperature higher than 100º F (37.8º C), the unit of blood should not be hung until the PHCP is notified and has the opportunity to give further prescriptions. The PHCP will likely prescribe that the blood be administered regardless of the temperature or may instruct the nurse to administer prescribed acetaminophen and wait until the temperature has decreased before administration, but the decision is not within the nurse's scope of practice to make. The nurse needs a PHCP's prescription to administer medications to the client.
What should blood transfusion tubing contain to trap fibrin clots or other debris that accumulate during blood storage?
Filter
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 primary health care provider to prescribe? Platelets Granulocytes Fresh-frozen plasma Packed red blood cells
Fresh-frozen plasma Fresh-frozen plasma is often used for volume expansion as a result of fluid and blood loss. It is rich in clotting factors and can be thawed quickly and transfused quickly. Platelets are used to treat thrombocytopenia and platelet dysfunction. Granulocytes may be used to treat a client with sepsis or a neutropenic client with an infection that is unresponsive to antibiotics. Packed red blood cells are a blood product used to replace erythrocytes.
If a history of adverse reactions, what should you do before blood administration?
Premedicate the patient with acetaminophen or diphenhydramine as prescribed. Oral meds should be given 30 min. before transfusion starts and IV meds immediately before transfusion is started.
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? Phlebotomist Medical student Registered nurse (RN) Blood bank technician
Registered nurse (RN Rationale: Depending on agency policy, two RNs or one RN and one licensed practical nurse (LPN) must check the label on the blood product together against the client's identification number, blood group, and complete name. This minimizes the risk of error in checking information on the blood bag and thereby minimizes the risk of harm or injury to the client. A blood bank technician verifies data with the nurse when the blood is obtained from the blood bank but does not verify information on the nursing unit or at the client's bedside. The other options are also incorrect.
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? a. Vital signs b. Skin color c. Urine output d. Latest hematocrit level
a. Vital Signs Rationale: A change in vital signs during the transfusion from baseline may indicate that a transfusion reaction is occurring. This is why the nurse assesses vital signs before the procedure and again after the first 15 minutes and thereafter per agency policy. The other options do not identify assessments that are a priority just before beginning a transfusion.
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 1300. The nurse calculates that the transfusion must be started by which time? 1330 1400 1430 1500
1330 Rationale: Blood must be hung as soon as possible (within 30 minutes) after it is obtained from the blood bank. After that time, the blood temperature will be higher than 50º F (10º C), and the blood could be unsafe for use. If blood will not be used within 30 minutes, it should be returned to the blood bank. For this reason, the remaining options are incorrect.
Begin the transfusion slowly under close supervision and if no reaction is noted within the first _______ minutes, flow can be increased to prescribed rate.
15
During transfusion the patient should be monitored for signs and symptoms of a transfusion reaction and the first _______ minutes are the most critical, requiring the nurse to _______ with the client.
15 Stay with the client!!!
The nurse has just received a prescription to transfuse a unit of packed red blood cells for an assigned client. What action should the nurse take next? Check a set of vital signs. Order the blood from the blood bank. Obtain Y-site blood administration tubing. Check to be sure that consent for the transfusion has been signed.
Check to be sure that consent for the transfusion has been signed. After receiving a prescription for a blood transfusion, the first action the nurse should take should be to check to be sure that consent for the transfusion has been signed by the client. If the client has consented, the nurse should then check a set of vital signs to be sure there is no contraindication for a transfusion at that time, such as an elevation in temperature. If the vital signs are acceptable, the nurse can then gather supplies to administer the transfusion and order the blood from the blood bank.
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 a temperature of 97.2º F (36.2º C), pulse of 108 beats per minute, blood pressure of 152/76 mm Hg, respiratory rate of 24 breaths per minute, 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? Collect a urine sample for analysis. Place the client in an upright position. Slow the rate of the blood transfusion. Compare current data to baseline data.
Compare current data to baseline data. Rationale: For the client receiving a blood transfusion, the nurse should monitor for potential complications of a transfusion. One of the complications is circulatory overload. Signs and symptoms of circulatory overload include cough, dyspnea, chest pain, wheezing on auscultation of the lungs, headache, hypertension, tachycardia and a bounding pulse, and distended neck veins. Based on the data in the question, the nurse should compare current data to baseline data. The nurse should also further assess the client for other signs and symptoms of circulatory overload. If the nurse still suspects this complication after comparing to baseline data, the nurse should then place the client in an upright position with the feet in a dependent position and slow the rate of the infusion. Collection of a urine sample should occur if the nurse suspects a transfusion reaction, such as a hemolytic reaction.
The nurse determines that a client is having a transfusion reaction. After the nurse stops the transfusion, which action should be taken next? Remove the intravenous (IV) line. Run a solution of 5% dextrose in water. Run normal saline at a keep-vein-open rate. Obtain a culture of the tip of the catheter device removed from the client.
Run normal saline at a keep-vein-open rate. If the nurse suspects a transfusion reaction, the nurse stops the transfusion and infuses normal saline at a keep-vein-open rate pending further primary health care provider prescriptions. This maintains a patent IV access line and aids in maintaining the client's intravascular volume. The nurse would not remove the IV line because then there would be no IV access route. Obtaining a culture of the tip of the catheter device removed from the client is incorrect. First, the catheter should not be removed. Second, cultures are performed when infection, not transfusion reaction, is suspected. Normal saline is the solution of choice over solutions containing dextrose because saline does not cause red blood cells to clump.
What gauge IV needle should be used to achieve maximum flow rate of blood products and prevent damage to RBCs?
18- or 19- gauge needle
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. Checks the expiration date Inspects for the presence of clots Checks the blood group and type Checks the blood identification number Hangs the blood within the specified time frame per agency policy
Checks the expiration date Hangs the blood within the specified time frame per agency policy Rationale: The nurse notes the expiration date on the unit of blood to ensure that the blood is fresh. Blood cells begin to deteriorate over time, so safe storage usually is limited to 35 days. Careful notation of the expiration date by the nurse is an essential part of the verification process before hanging a unit of blood. The nurse also needs to hang the blood within the specified time frame after receiving it from the blood bank per agency policy to ensure that the blood being transfused is fresh. The blood bank keeps the blood regulated at a specific temperature, and therefore it must be infused within a specified time frame once received on the unit. The nurse also notes the blood identification (unit) number, blood group and type, and client's name, but this is not specifically related to the degradation of blood cells. The nurse also inspects the unit of blood for leaks, abnormal color, clots, and bubbles and returns the unit to the blood bank if clots are noted. Again, this is not related to the degradation of blood cells over time.
The 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 100.1º F (37.8º C). What action should the nurse take first? Assess the client for other symptoms. Slow the blood transfusion and monitor the client's vital signs. Remind the client that these are expected reactions to a blood transfusion. Discontinue the infusion and start an infusion of normal saline using new tubing.
Discontinue the infusion and start an infusion of normal saline using new tubing. Rationale: Signs of a transfusion reaction include fever, chills, tachycardia, tachypnea, dyspnea, hives or skin rash, flushing, backache, and decreased blood pressure. If the client shows any symptoms of a blood transfusion reaction, the nurse needs to discontinue the infusion immediately and start an infusion of normal saline using new tubing connected to the hub of the intravenous insertion site. The nurse should stay with the client and monitor his or her condition while asking a colleague to notify the primary health care provider immediately.
