NCLEX Book Question
The nurse has a prescription to administer whole blood to a client who does not currently have an intravenous (IV) line inserted. When obtaining supplies to start the blood infusion, the nurse should select an angiocatheter of at least which size? 1.19 gauge 2.21 gauge 3.24 gauge 4.26 gauge
ANS 1 Blood components are usually administered with at least a 19-gauge needle, cannula, or catheter. Larger sizes (e.g., 18- or 16-gauge) may be preferred if rapid transfusions are given. Smaller needles can be used for platelets, albumin, and clotting factor replacement.
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? Click on the image to indicate your answer.
ANS 3 The tubing used for blood administration has an in-line filter. The filter helps to ensure that any particles larger than the size of the filter are caught in the filter and are not infused into the client. Tinted tubing (option 2) is incorrect because blood does not need to be protected from light. The tubing should be macrodrip, not microdrip (option 4), to allow blood to flow freely through the drip chamber. An air vent (option 1) is unnecessary because the blood bag is not made of glass.
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?"
ANS 1 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.
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? 1.1330 2.1400 3.1430 4.1500
ANS 1 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 50°F (10°C), and the blood could be unsafe for use. For this reason, the remaining options are incorrect.
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 (38.2°C) orally from a baseline of 99.2°F (37.3°C) 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
ANS 1 Septicemia occurs with the transfusion of blood contaminated with microorganisms. Signs include chills, fever, vomiting, diarrhea, hypotension, and the development of shock. Hyperkalemia causes weakness, paresthesias, abdominal cramps, diarrhea, and dysrhythmias. Circulatory overload causes cough, dyspnea, chest pain, wheezing, tachycardia, and hypertension. A delayed transfusion reaction can occur days to years after a transfusion. Signs include fever, mild jaundice, and a decreased hematocrit level
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
ANS 4 The client who has neutropenia may receive a transfusion of granulocytes, or WBCs. These clients often have severe infections and are unresponsive to antibiotic therapy. The nurse notes the results of follow-up WBC counts and differential to evaluate the effectiveness of the therapy. The nurse also continues to monitor the client for signs and symptoms of infection. Erythrocyte count and hemoglobin and hematocrit levels are determined after transfusion of packed red blood cells.
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
ANS 1 The nurse returns the blood transfusion bag containing any remaining blood to the blood bank. This allows the blood bank to complete any follow-up testing procedures needed once a transfusion reaction has been documented. The other options identify incorrect departments.
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 the blood from light
ANS 1 The tubing used for platelet administration has an in-line filter. This helps ensure that any particles larger than the size of the filter are caught in the filter and are not infused into the client. Self-sealing valves and Y-ports are unnecessary. These features may be used to administer medication. No medication is infused through the intravenous (IV) line that the blood is infusing through. If the client needed medications as a result of a complication while receiving blood or for another reason, it would need to be administered via a different IV site and line. Platelets do not need to be protected from light.
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.Vital signs 2.Skin color 3.Urine output 4.Latest hematocrit level
ANS 1 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.
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
ANS 1 Fluid overload is one of the potential complications of a blood transfusion and is characterized by a variety of signs, including high blood pressure, fluid in the lungs manifesting as crackles, and distended jugular veins. This type of transfusion reaction is prevented by pretreating the client with a diuretic such as furosemide. Acetaminophen and aspirin are analgesics, which can also be used for analgesia. These medications may reduce fever as well but do not treat fluid overload.
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.
ANS 1,2 A donation of the client's own blood before a scheduled procedure is autologous. Donating autologous blood to be reinfused as needed during or after surgery reduces the risk of disease transmission and potential transfusion complications. The next most effective way is to ask a family member to donate blood before surgery. Blood banks do not provide extra screening on request. Preoperative iron supplements are helpful for iron deficiency anemia but are not helpful in replacing blood lost during the surgery. Vitamin C enhances iron absorption, but also is not helpful in replacing blood lost during surgery.
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.Lower back pain 6.Difficulty breathing
ANS 1,4,5,6 The nurse should instruct the client to immediately report signs of a transfusion reaction, which can include chest pain, lower back pain, chills, itching, rash, or difficulty breathing. These signs of transfusion reaction would require the nurse to stop the transfusion. Fatigue and sleepiness are unrelated to transfusion reaction.
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
ANS 1,5 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 told by a health care provider that a client in hypovolemic shock will require plasma expansion. The nurse should prepare which supplies for transfusion? 1.Bag of platelets with filtered tubing 2.Bottle of albumin with vented tubing 3.Cryoprecipitate bag with vented tubing 4.Infusion pump and bag of packed red blood cells
ANS 2 Albumin may be used as a plasma expander. Albumin is supplied in a bottle, and vented tubing is required for transfusion. Platelets are used when the client's platelet count is low. Cryoprecipitate is useful in treating bleeding from hemophilia or disseminated intravascular coagulopathy because it is rich in clotting factors. Cryoprecipitate is usually supplied in bags, so vented tubing is not required. Packed red blood cells replace erythrocytes and are not a plasma expander.
Following infusion of a unit of packed red blood cells, 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 intravenous fluids. 4.Consult with the health care provider (HCP) regarding initiation of oxygen therapy.
ANS 2 New onset of tachycardia, bounding pulses, and crackles and wheezes posttransfusion is evidence of fluid overload, a complication associated with blood transfusions. Placing the client in a high Fowler's (upright) position will facilitate breathing. Measures that increase blood return to the heart, such as leg elevation and administration of IV fluids, should be avoided at this time. In addition, administration of fluids cannot be initiated without a prescription. Consulting with the HCP regarding administration of oxygen may be necessary, but positional changes take a short amount of time to do and should be initiated first.
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
ANS 2 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.
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 2.Acetaminophen 3.Diphenhydramine 4.Acetylsalicylic acid
ANS 3 An urticaria-type reaction is characterized by a rash accompanied by pruritus. This type of transfusion reaction is prevented by pretreating the client with an antihistamine such as diphenhydramine. The remaining medications would not prevent an urticaria-type reaction. Acetaminophen may be prescribed before the administration to assist in preventing an elevated temperature.
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 mostlikely is experiencing which complication of blood transfusion therapy? 1.Bacteremia 2.Hypovolemia 3.Circulatory overload 4.Transfusion reaction
ANS 3 Circulatory overload is caused by the infusion of blood at a rate too rapid for the client to tolerate. With circulatory overload, crackles are present in addition to dyspnea. An allergic reaction, which is one type of blood transfusion reaction, would produce symptoms such as flushing, dyspnea, itching, and a generalized rash. Hypovolemia is not likely a complication of blood transfusion. With bacteremia, the client would have a fever, which is not part of the clinical picture presented.
The nurse overhears a health care provider (HCP) stating that a client diagnosed with disseminated intravascular coagulation (DIC) requires a transfusion. Which blood product should the nurse anticipate that the HCP will write a prescription for? 1.Albumin 2.Platelets 3.Cryoprecipitate 4.Packed red blood cells
ANS 3 Cryoprecipitate is useful in treating bleeding from hemophilia or DIC because it is rich in clotting factors. Albumin may be used as a plasma expander in hypovolemia with or without shock. Platelets are used when the client's platelet count is low. Packed red blood cells replace erythrocytes, not fibrinogen.
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
ANS 3 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 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 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? 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.
ANS 3 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.
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 health care provider to prescribe? 1.Platelets 2.Granulocytes 3.Fresh-frozen plasma 4.Packed red blood cells
ANS 3 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.
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 100.6°F (38.1°C) 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 2 tablets of acetaminophen and begin the transfusion.
ANS 3 If the client has a temperature higher than 100°F (37.8°C), the unit of blood should not be hung until the HCP is notified and has the opportunity to give further prescriptions. The HCP likely will 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 an HCP's prescription to administer medications to the client.
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 (IV) 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.
ANS 3 If the nurse suspects a transfusion reaction, the nurse stops the transfusion and infuses normal saline at a keep-vein-open rate pending further 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.
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? 1.Check a set of vital signs. 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.
ANS 4 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.
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
ANS 4 If several units of blood are to be administered rapidly, a blood warmer should be used. Rapid transfusion of cool blood places the client at risk for cardiac dysrhythmias. To prevent this, the nurse warms the blood with a blood-warming device. Pulse oximetry and cardiac monitoring equipment are useful for the early assessment of complications but do not reduce the occurrence of cardiac dysrhythmias. Electronic infusion devices are not helpful in this case because the infusion must be rapid, and infusion devices generally are used to control the flow rate. In addition, not all infusion devices are made to handle blood or blood products.
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
ANS 4 Platelets are necessary for proper blood clotting. The client with insufficient platelets may exhibit frank bleeding or oozing of blood from puncture sites, wounds, and mucous membranes. Increased hemoglobin and hematocrit levels would occur when the client has received a transfusion of red blood cells. An elevated temperature would decline to normal after infusion of granulocytes because these cells were instrumental in fighting infection in the body.
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 100.1°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.
ANS 4 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 health care provider immediately.
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
ANS 4 The client is most likely experiencing an allergic transfusion reaction based on the clinical manifestation of pruritus. Bacteremia usually manifests with fever. With fluid overload, the client has the presence of crackles in the lungs in addition to dyspnea. Other clinical manifestations of fluid overload include hypertension, a bounding pulse, distended jugular veins, restlessness, and confusion. Hypovolemic shock is not likely a transfusion reaction because intravascular fluid is being administered.
