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Blood Transfusions AH 2 Test 3

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Blood Transfusions AH 2 Test 3

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Sample practice questions

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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?
  1. Administer the histamine-1 blocker, benadryl, IV
  2. Assess the client for further complications
  3. Notify the laboratory and HCP
  4. Stop the transfusion and change the tubing at the hub
    The priority in this situation is to prevent a further reaction if possible. Stopping the transfusion and changing the fluid out at the hub will prevent any more of the transfusion from entering the client's bloodstream.
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?
  1. Call the HCP to question the order because blood must infuse within four hours
  2. Infuse each unit for four hours, the maximum rate for a unit of blood
  3. Notify the lab to split each unit into half units and infuse each half for four hours
    The correct procedure for administering a unit of blood over eight hours is to have the unit split into halves. Each half unit is treated as a new unit and checked accordingly. This slower administration allows the compromised client, such as one with heart failure, to assimilate the extra fluid volume.
  4. Retrieve the blood from the laboratory and run each unit at an eight hour rate
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?
  1. Assess the urine output on a client who has had a blood transfusion reaction
  2. Assist the client who received 10 units of platelets in brushing their teeth
    The UAP can assist a client to brush the teeth. Instructions about using soft bristle toothbrushes and the need to report to the nurse any pink or bleeding gums should be given prior to delegating the procedure.
  3. Auscultate the lung sounds of a client before a transfusion
  4. Take the first 15 min. of vital signs on a client receiving a unit of packed RBCs
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)
  1. Obtain a signed consent
    a - The client must give permission to receive blood or blood products because of the nature of potential complications. c - Because infusing IV fluids can cause a fluid volume overload, the nurse must assess for congestive heart failure. Assessing the lungs includes auscultating for crackles and other signs of left-sided heart failure. Additional assessment findings of JVD, peripheral oedema, & liver engorgement indicate right-sided failure d - Checking for allergies is important prior to administering any medication. Some meds are administered prior to blood administration
  2. Initiate a 22G IV
  3. Assess the client's lungs
    a - The client must give permission to receive blood or blood products because of the nature of potential complications. c - Because infusing IV fluids can cause a fluid volume overload, the nurse must assess for congestive heart failure. Assessing the lungs includes auscultating for crackles and other signs of left-sided heart failure. Additional assessment findings of JVD, peripheral oedema, & liver engorgement indicate right-sided failure d - Checking for allergies is important prior to administering any medication. Some meds are administered prior to blood administration
  4. Check for allergies
    a - The client must give permission to receive blood or blood products because of the nature of potential complications. c - Because infusing IV fluids can cause a fluid volume overload, the nurse must assess for congestive heart failure. Assessing the lungs includes auscultating for crackles and other signs of left-sided heart failure. Additional assessment findings of JVD, peripheral oedema, & liver engorgement indicate right-sided failure d - Checking for allergies is important prior to administering any medication. Some meds are administered prior to blood administration
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?
  1. Attach an hourly drainage collection bag to the unit and discard the drainage
  2. Have another nurse verify the unit number before reinfusing the blood
  3. Infuse the drainage into the client when a prescribed amount fills the chamber
    A cell saver is a device to catch the blood lost during orthopedic surgeries to reinfuse into the client, rather than giving the client donor blood products. the cells are washed with saline & reinfused through a filter into the client. The salvaged cells cannot be stored & must be used within four hours or discarded because of bacterial growth.
  4. Replace the unit with a continuous passive motion unit and start it on low
6) The nurse is caring for clients on a medical floor. After the shift report, which client should be assessed first?
  1. The client diagnosed with Crohn's disease who is complaining of perineal discomfort
  2. The client diagnosed with leukemia who has a hematocrit of 18% and petechiae covering the body
  3. The client who has two thirds of the through a blood transfusion and has had no complaints of dyspnea or hives
  4. The client with peptic ulcer disease who called over the intercom to say that he is vomiting blood
    This client has a potential for hemorrhaging and is reporting blood in the vomitus. This client should be assessed first.
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?
  1. Ativan, a tranquilizer
  2. Epogen, a biologic response modifier
    Epogen and Procrit are forms of erythropoietin, the substance in the body that stimulates the bone marrow to produce RBCs. A client may be prescribed iron preparations to prevent depletion of iron stores and erythropoietin to increase RBC production. A unit of blood can be withdrawn once a week beginning at six months prior to surgery. No phlebotomy will be done within 72 hours of surgery
  3. Prednisone, a glucocorticoid
  4. Zithromax, an antibiotic
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?
  1. Have the client sign a consent for an exploratory laparotomy
  2. Initiate an IV with an 18G needle and hang normal saline
    The first action in a situation in which the nurse suspects the client has a fluid volume loss is to replace volume as quickly as possible.
  3. Notify the S/O of the client's admission
  4. Type & crossmatch for RBCs immediately (STAT)
9) An O+ patient needs a transfusion of red blood cells but no O+ red blood cells are available. Which red blood cells can be given instead?
  1. AB+
  2. AB−
  3. B+
  4. O−
    O− red blood cells can be given to anyone, including O+ patients. O− red blood cells are considered universal because they lack A, B, and Rh antigens. Conversely, O patients cannot receive A, B, or AB red blood cells. These red blood cells have A and B antigens. O patients have anti-A and anti-B antibodies that would attack these antigens upon blood transfusion. This would cause a hemolytic transfusion reaction, which can be dangerous for the patient. Therefore, the only red blood cells an O+ patient can receive are O+ and O−.
10) Why is donated blood kept refrigerated?
  1. To increase its oxygen-carrying capacity
  2. To prevent coagulation
  3. To prevent the blood from producing alloantibodies
  4. To slow bacterial growth
    Cold temperatures significantly inhibit the growth of bacteria, which would otherwise grow in the blood and make it unsafe for transfusion.
11) Which of these people should NOT donate blood?
  1. A breastfeeding mother with a month-old newborn
    Breastfeeding mothers should not donate blood for at least six weeks after pregnancy. This 6-week period allows their body to recover and maintain adequate iron and nutrient levels for both themselves and their baby.
  2. Someone who had wisdom teeth removed a week ago
  3. Someone who received a measles immunization two months ago
  4. Someone with an aspirin allergy

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