Blood Transfusion NCLEX – Flashcards

Correct Answer A Change in vital signs during the transfusion from the baseline may indicate that a transfusion reaction is occuring. This is why nurse assesses vital signs before the procedure and again after 15 mintues. The other options do not identify assessment that are required just before beginning a transfusion.

"Answer C Rationale: A unit of blood should be administered within a 4 hour period of time. The nurse should discontinue the transfusion, document the findings and notify the blood bank. The agency policy will need to be followed concerning the documentation process and notification of appropriate personnel. Continuing the transfusion with the "open" unit will expose the client to an increase risk of injury."

"Correct answer: Answer 1. 1. O- negative blood is considered the universal donor because it does not contain the antigens A, B, or Rh. (AB+ is considered the universal recipient because a person with this blood type has all the anti-gens on the blood). 2.A+ blood contains the antigen A that the client will react to, causing the development of antibodies. The unit being Rh+ is compatible with the client. 3.B+ blood contains the antigen B that the client will react to, causing the development of anti-bodies. The unit being Rh+ is compatible with the client. 4.This client does not have antigens A or B on the blood. Administration of these types would cause an antigen/antibody reaction within the client's body, resulting in a massive hemolysis of the client's blood and death."

The correct answer is 4. The patietn is experiencing a transfusion reaction. The immediate nursing action is to stop the transfusion and maintain a patent IV line. The other options may be indicated but aren't the priority in this case.

Correct: 4 The most likely time for a blood transfusion reaction to occur is during the first 15 minutes or first 50 mL of the infusion. If a blood transfusion reaction does occur, it is imperative to keep an established I.V. line so that medication can be administered to prevent or treat cardiovascular collapse in case of anaphylaxis. PRBCs should be administered through a 19-gauge or larger needle; a peripherally inserted central catheter line is not recommended, in order to avoid a slow flow. RBCs will hemolyze in dextrose or lactated Ringer's solution and should be infused with only normal saline solution.

"F, D, B, A, C, E - The nurse would first verify the physician's order for the blood transfusion and ensure that the client has been informed about the procedure and has signed an informed consent. Once this has been done, the nurse would ensure that at least an 18- or 19-gauge intravenous needle is inserted into the client. Blood has a thicker and stickier consistency than intravenous solutions and using an 18- or 19-gauge catheter ensures that the bore of the catheter is large enough to prevent damage to the blood cells. Next, the blood is obtained from the blood bank, once the nurse is sure that the client has been informed and has an adequate access for administering the blood. Once the blood has been obtained, two registered nurses, or one registered and a licensed practical nurse (depending on agency policy), must together check the label on the blood product 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. The nurse should measure vital signs and assess lung sounds and then hang the transfusion."`

Correct: 3 With fluid overload, the client has the presence of crackles in addition to dyspnea. An allergic reation, a type of blood transfusion reaction, would produce symptoms such as flushing, dyspnea, itching, and a generalized rash. Hypovolemia is not complication of blood transfusions. With bacteriemia, the client would have fever, a symptom not presented.

Correct B Patients who are likely to have a transfusion reaction will more often exhibit signs within the first 15 minutes that the blood is infusing

Correct: 3 "1. ""Obtain vital signs..."" - vital sings should be obtained, and the physician notified after treatment is discontinue. The unit in quesiton should not be restarted, and any other units that were issued should not be implemented. 2. ""Slow the infusion..."" - just slowing the infusino will not resolve the issue of an allergic reaction to the treatment 3. ""Stop the infusion..."" - (CORRECT): The symptoms of feeling chilllded, being short of breath, and having back pain coudl indicate an acute hemolytic reaction. This medical emergency requires swift action on the part of the nurse, including immediately discontinuing the infusion, flushing the IV site, and saving the unit of blood in question for testing. 4. ""Administer PRN pain medication..."" - Treating the symptoms of the reaction will not resolve the issue of an allergic reactio to the treatment"

Correct 3 "1. Oral surgeries are associated with transientbacteremia, and the client cannot donate for 72hours after an oral surgery.2.The client cannot donate blood following ubella immunizations for one (1) month. 3. CORRECT The client cannot donate blood for 6months after a pregnancy because of thenutritional demands on the mother. 4.Recent allergic reactions prevent donationbecause passive transference of hypersensitiv-ity can occur. This client has an allergy thatdeveloped during childhood"

Correct 2 "1. Blood will coagulate if left out for an extended period of, but blood is stored with a preservative that prevents this and prolongs the life of the blood. 2. (CORRECT). Blood is a medium for bacterial growth, and any bacteria contaminating the unit will begin to grow if left outside of a controlled refrigerated temperature for longer than four (4) hours, placing the client at risk for septicemia. 3. Blood components are stable and do not break down after four (4) hours. 4. These are standard nursing and laboratory procedures to prevent the complication of septicemia."

Correct: D Before hanging a transfusion, the registered nurse must check the unit with ANOTHER RN or with a licensed practical (vocational) nurse, depending on agency policy. Checking blood products is not in the unit secretary's or phlebotimist's scope of practice. The physician assistant is not another RN or licensed practical nurse.

Correct A - no rationale

Answer: B "Rationale: A blood infusion must be administered via a separate IV line. The other responses indicate to the client their request is being considered"

Correct: 4 "1. Unlicensed nursing assistants cannot assess. The nurse cannot delegate assessment. 2. The likelihood of a reaction is the greatest during the first 15 minutes of a transfusion.The nurse should never leave the client until after this time. The nurse should take and assess the vital signs during this time. 3. Auscultation of the lung sounds and administering blood based on this information are the nurse's responsibility. Any action requiring nursing judgment cannot be delegated. 4. The unlicensed nursing assistant 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 should be given prior to delegating the procedure. (CORRECT) TEST-TAKING HINT: The test taker must be aware of delegation guidelines. The nurse cannot delegate assessment or any intervention requiring nursing judgment. Options "1," "2," and "3" require judgment and cannot be delegated to an unlicensed assistant."

Correct: 2 "1,-Blood will coagulate if left out for an extended period, but blood is stored with a preservative that prevents this and prolongs the life of the blood. 2.-Blood is a medium for bacterial growth, and any bacteria contaminating the unit will begin to grow if left outside of a con- trolled refrigerated temperature for longer than four (4) hours, placing the client at risk for septicemia. . 3)Blood components are stable and do not break down at four 4.)These are standard nursing and laboratory procedures to prevent the complication of septicemia."

Correct: A Red blood cells contain antigens and antibodies that must be matched between donor and recipient. The blood products in options 2-4 do not contain red cells. Thus, they require no cross-match.

Correct: D Rationale: Infectious viruses, such as human immunodeficiency virus (HIV), human herpesvirus, hepatitis B and C type 6 (HSV-6), Epstein-Barr virus (EBV), human T-cell leukemia virus type 1 (HTLV-1), and cytomegalovirus (CMV), and other agents, such as the agent that causes malaria, can be transmitted by blood transfusion. Leukocyte-reduced blood products drastically reduce the risk of blood transfusion-associated viral infections, including CMV.

B) stop the transfusion because chills, headache, and nausea are all signs of transfusion reaction

Correct: B GVHD occurs when white blood cells in donor blood attack the tissues of an immunocompromised recipient. This process can occur within a month of the transfusion. Options 1 and 4 may be a thought, but the nurse must remember that immunocompromised transfusion recipients are at risk for GVHD

Correct: C For all causes of hemolysis, a major focus of treatment is to maintain renal function. When RBCs are hemolyzed, the hemoglobin molecule is released and filtered by the kidneys. The accumulation of hemoglobin molecules can obstruct the renal tubules and lead to acute tubular necrosis

Correct - 4 - no rationale

Correct: C ANSWER C - Normal saline, an isotonic solution, should be used when priming the IV line to avoid causing hemolysis of RBCs. Ideally, blood products should be infused as soon as possible after they are obtained; however, a 20-minute delay would not be unsafe. Large-gauge IV catheters are preferable for blood administration; if a smaller catheter must be used, normal saline may be used to dilute the RBCs. Although it is appropriate to instruct clients to notify the nurse if symptoms of a transfusion reaction such as shortness of breath or chest pain occur, it will cause unnecessary anxiety to indicate that a serious reaction is likely to occur. Focus: Prioritization

Answer A is correct. The client is exhibiting symptoms of fluid volume excess; slowing the rate is the proper action. The nurse would not stop the infusion of blood, as in answer C, and answers B and D would not help.

A, septicemia occurs with transfusion of blood contaminated with microorganisms. Signs include chills, fever, vomiting, diarrhea, hypotension, and development of shock. Hyerkalemia causes weakness, paresthesia, abdominal cramps, diarrhea, and dysrythmias. Circulatory overload causes cough, dyspnea, chest pain, wheezing, tachycardia, and hypertension. Delayed transfusion reaction can occer days or weeks after transfuison. Signs include fever, mild jaundice, and a decrease hematocrit level.

Correct:" A "0.9 percent sodium chloride is normal saline. This solution has the same osmolarity as blood. Its use prevents red cell lysis. The solutions given in options 2 and 3 are hypotonic solutions and can cause red cell lysis. The solution in option 4 may anticoagulate the patient and result in bleeding."

Correct A "The fresh frozen plasma should be administered as rapidly as possible and should be used within 2 hours of thawing. Fresh frozen plasma is infused using any straight-line infusion set. Any existing IV should be interrupted while the fresh frozen plasma is infused, unless a second IV line has been started for the transfusion."

Correct C The correct answer is normal saline. Normal saline is the only solution used to flush the tubing during a blood transfusion. The other solutions listed aren't indicated and may hemolyze the RBCs.

Correct A Hanging for a longer four hours creates an increased risk of sepsis, which is why the nurse wants to complete the unit transfusion in less than four hours. The remaining items are not likely to happen.

Correct: 1 Asking the client about personal experience with tranfusion therapy provides a good starting point for client teaching about this procedure. Options 3 & 4 are not helpful because they may elicit a fearful response from the client. Although determining whether the client knows the reason for the transfusion is important, option 2 is not an appropriate statement in terms of eliciting information from the client regarding an understanding of the need for the transfusion.

Correct 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 physician 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.

Correct: 2 The administration of antipyretics and antihistamines before initiation of the transfusion in the frequently transfused client can decrease the incidence of febrile reactions. Febrile reactions are immune-mediated and are caused by antibodies in the recipient that are directed against antigens present on the granulocytes, platelets, and lymphocytes in the transfused component. They are the most common transfusion reaction and may occur with onset, during transfusion, or hours after transfusion is completed.

Correct: A The nurse should return the blood to the blood bank because the gas bubbles in the bag indicate possible contamination. If the nurse were going to administer the blood, the nurse would use filter tubing to trap the particulate matter. Although normal saline can be infused concurrently with the blood, NS or any other substance should never be added to the blood in a blood bag. The blood should not be agitated this can harm the RBCs.

*2.) The first action in a situation in which the nurse suspects the client has a fluid volume loss is to replace the volume as quickly as possible (CORRECT). 1.) This should be done, but the client requires the IV fluids first because they are at risk for shock (omit #1). 3.)The client will probably need to have surgery to correct the source of the bleeding, but stabilizing the client with fluid resuscitation is first priority (omit #3). 4.) This is the last thing on this list in order of priority (omit #4).

Correct: 1, 3, 4

"Correct Answer B: If the client has a temperature higher than 100 degrees, the unit of blood should not be hung until the physician is notified and has the opportunity to give further prescriptions. The physician will likely prescribe that the blood be administered regardless of the temperature, but the decision is not within the nurses's scope of practice to make. The nurse needs a physician's prescription to administer medications to the client. Options A, C, and D can all be excluded as they indicate beginning the transfusion."

Correct A The blood must be stopped at once, and then normal saline should be infused to keep the line patent and maintain blood volume.

Correct: B ANSWER B. The defining characteristic of pernicious anemia, a megaloblastic anemia, is lack of the intrinsic factor, which results from atrophy of the stomach wall. Without the intrinsic factor, vitamin B12 cannot be absorbed in the small intestines, and folic acid needs vitamin B12 for DNA synthesis of RBCs. The gastric analysis was done to determine the primary cause of the anemia. An elevated excretion of the injected radioactive vitamin B12, which is protocol for the first and second stage of the Schilling test, indicates that the client has the intrinsic factor and can absorb vitamin B12 into the intestinal tract. A sedimentation rate of 16 mm/hour is normal for both men and women and is a nonspecific test to detect the presence of inflammation. It is not specific to anemias. An RBC value of 5.0 million is a normal value for both men and women and does not indicate anemia.

Correct answer: 3. Deferoxamine (Desferal) Rationale: Beta-Thalassemia is an autosomal recessive disorder characterized by the reduced production of one of the globin chains in the synthesis of hemoglobin (both parents must be carriers to produce a child with Beta-Thalassemia major). The major complication of long-term transfusion therapy is hemosiderosis. To prevent organ damage from too much iron, chelation therapy with either deferasirox (Exjade) or deferoxamine (Desferal) may be prescribed. Deferoxamine is classified as an antidote for acute iron toxicity. Dalteparin is an anticoagulant used as prophylaxis for postoperative DVT. Meropenem is an antibiotic. Metoprolol is a Beta-blocker used to treat HTN.