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1)
The client receiving a unit of packed red blood cells begins to chill and develop hives. Which action should be the nurse's first response?
- Administer the histamine-1 blocker, benadryl, IV
- Assess the client for further complications
- Notify the laboratory and HCP
- Stop the transfusion and change the tubing at the hub
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2)
The HCP orders two units of blood to be administered over eight hours each for a client diagnosed with heart failure. Which intervention(s) should the nurse take?
- Call the HCP to question the order because blood must infuse within four hours
- Infuse each unit for four hours, the maximum rate for a unit of blood
- Notify the lab to split each unit into half units and infuse each half for four hours
- Retrieve the blood from the laboratory and run each unit at an eight hour rate
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3)
The nurse and an unlicensed assistive personnel (UAP) are caring for clients on an oncology floor. Which nurse task would be delegated to the UAP?
- Assess the urine output on a client who has had a blood transfusion reaction
- Assist the client who received 10 units of platelets in brushing their teeth
- Auscultate the lung sounds of a client before a transfusion
- Take the first 15 min. of vital signs on a client receiving a unit of packed RBCs
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4)
The client has a hematocrit of 22.3% and a hemoglobin of 7.7 g/dL. The HCP has ordered two units of packed RBC's to be transfused. Which interventions should the nurse implement? (Select all that apply)
- Obtain a signed consent
- Initiate a 22G IV
- Assess the client's lungs
- Check for allergies
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5)
The client undergoing knee replacement surgery has a "cell saver" apparatus attached to the knee when he arrives in the post anesthesia care unit (PACU). Which intervention should the nurse implement to care for this drainage system?
- Attach an hourly drainage collection bag to the unit and discard the drainage
- Have another nurse verify the unit number before reinfusing the blood
- Infuse the drainage into the client when a prescribed amount fills the chamber
- Replace the unit with a continuous passive motion unit and start it on low
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6)
The nurse is caring for clients on a medical floor. After the shift report, which client should be assessed first?
- The client diagnosed with Crohn's disease who is complaining of perineal discomfort
- The client diagnosed with leukemia who has a hematocrit of 18% and petechiae covering the body
- The client who has two thirds of the through a blood transfusion and has had no complaints of dyspnea or hives
- The client with peptic ulcer disease who called over the intercom to say that he is vomiting blood
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7)
The client is scheduled to have a total hip replacement in two months and has chosen to prepare for autologous transfusion. Which medications would the nurse administer to prepare the client?
- Ativan, a tranquilizer
- Epogen, a biologic response modifier
- Prednisone, a glucocorticoid
- Zithromax, an antibiotic
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8)
The client is admitted to the emergency department after a motor vehicle accident. The nurse notes profuse bleeding from a right sided injury. Which intervention should the nurse implement first?
- Have the client sign a consent for an exploratory laparotomy
- Initiate an IV with an 18G needle and hang normal saline
- Notify the S/O of the client's admission
- Type & crossmatch for RBCs immediately (STAT)
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9)
Which of these people should NOT donate blood?
- A breastfeeding mother with a six-week-old newborn
- Someone who had wisdom teeth removed a week ago
- Someone who received a measles immunization two months ago
- Someone with an aspirin allergy
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10)
An O+ patient needs an emergency transfusion but the laboratory does not have any O+ blood available. Which type of blood could be given to the patient instead?
- AB+
- AB−
- B+
- O−
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11)
Why is donated blood kept refrigerated?
- To increase its oxygen-carrying capacity
- To prevent coagulation
- To prevent the blood from producing alloantibodies
- To slow bacterial growth
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