Ticket to clinical 7
A nurse is preparing to administer blood to a client. The unit of blood on hand is type B, and the client has type AB blood. Which of the following actions should the nurse take ?
Administer the blood as ordered (Type B blood can be transfused to type AB)
A nurse is preparing to administer a unit of packed red blood cells to a client. Which of the following should the nurse plan to take?
Remain with the client for the first 15 minutes of transfusion.
A nurse is selecting staff member to double check blood label with client ID bracelet prior to infusing a unit of blood. nurse should identify that which of the following persons is qualified?
Oncology nurse (another nurse or provider must double check the blood label and client ID prior to an infusion)
A nurse is assessing a client who is receiving a unit of packed red blood cells. Which of the following findings is a manifestation of acute hemolytic reaction?
client report low back pain
A nurse is caring for a client who is receiving a transfusion of PRBC (packed red blood cells) and suspects that a client is experiencing a hemolytic reaction. Which of the following interventions is the priority?
Stop the transfusion
A nurse is monitoring a client who reports having chills and back pain during a blood transfusion. Which of the following action should the nurse take first?
Stop the transfusion
A nurse is caring for a client who is receiving cisplatin for treatment of ovarian cancer. The client's most recent CBC is shown below. It is important for the nurse to consider which of the following for the client?
The client has an increased risk of infection.
A charge nurse is supervising a newly licensed nurse care for a client who is receiving a transfusion of packed RBC. The nurse suspects a possible hemolytic reaction. After stopping the blood transfusion, which of the following actions by the new nurse requires intervention by the charge nurse?
The nurse starts the transfusion of another unit of blood product.
The nurse receives a unit of packed RBCs from a blood bank and notes that the time is 1130. The nurse should begin the infusion at which of the following times?
As soon as the nurse can prepare the client and the administration set. (The nurse should infuse the blood as soon as possible and complete the procedure within 4 hr.)
A nurse is caring for a client who is to receive a unit of packed red blood cells. The nurse should prime the blood administration to being using which of the following IV solutions?
0.9% sodium chloride (The nurse should prime the tubing was 0.9% sodium chloride as this is the only IV solution that does not hemolyze red blood cells.)