Blood Transfusion NCLEX

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1. A 28-year old client with cancer is afraid of experiencing a febrile Correct: 2

reaction associated with blood transfusions. He asks the nurse if The administration of antipyretics and antihistamines before
this will happen to him. The nurse's best response is which of the initiation of the transfusion in the frequently transfused client can
following? decrease the incidence of febrile reactions. Febrile reactions are
1) Febrile reactions are caused when antibodies on the surface of immune-mediated and are caused by antibodies in the recipient
blood cells in the transfusion are directed against antigens of the that are directed against antigens present on the granulocytes,
recipient. 2) Febrile reactions can usually be prevented by platelets, and lymphocytes in the transfused component. They are
administering antipyretics and antihistamines before the start of the most common transfusion reaction and may occur with onset,
the transfusion. 3) Febrile reactions are rarely immune-mediated during transfusion, or hours after transfusion is completed.
reactions and can be a sign of hemolytic transfusion. 4) Febrile
reactions primarily occur within 15 minutes after initiation of the
transfusion and occur during the blood transfusion.
2. A 52-year-old woman is admitted with a new diagnosis of Correct: 3
gastrointestinal (GI) bleed. The physician has ordered the client to "1. ""Obtain vital signs..."" - vital sings should be obtained, and
receive 2 units of packed red blood cells (PRBCs) for a the physician notified after treatment is discontinue. The unit in
hemoglobin (Hgb) of 6.8g/dL. The nurse begins the infusion of the quesiton should not be restarted, and any other units that were
first unit at 100mL/hr. Firfteen minutes after the start of the issued should not be implemented.
infusion, the client complains that she is feeling chilled, is short 2. ""Slow the infusion..."" - just slowing the infusino will not resolve
of breath, and is experiencing lumbar pain rated 8 on a 1-10 the issue of an allergic reaction to the treatment
scale. Whic of the following should be the nurse's FIRST action. 3. ""Stop the infusion..."" - (CORRECT): The symptoms of feeling
"1. Obtain vital signs and notify the physician of potential reaction chilllded, being short of breath, and having back pain coudl
2. Slow the infusion to 75mL/hr and reassess in 15 minutes indicate an acute hemolytic reaction. This medical emergency
3. Stop the infusion and run normal saline (NS) to keep the vein requires swift action on the part of the nurse, including
open (KVO) immediately discontinuing the infusion, flushing the IV site, and
4. Administer PRN pain medication as ordered, apply oxygen at 2 saving the unit of blood in question for testing.
L/min, and provide an additional blanket" 4. ""Administer PRN pain medication..."" - Treating the symptoms
of the reaction will not resolve the issue of an allergic reactio to
the treatment"
3. "73. A client brought to the emergency department states that he Correct - 4 - no rationale
has
accidentally been taking two times his prescribed dose of
warfarin
(Coumadin) for the past week. After noting that the client has no
evidence of obvious bleeding, the nurse plans to do which of the
following?
1. Prepare to administer an antidote.
2. Draw a sample for type and crossmatch and transfuse the
client.
3. Draw a sample for an activated partial thromboplastin time
(aPTT) level.
4. Draw a sample for prothrombin time (PT) and international
normalized ratio (INR)."
4. About ten minutes after the nurse begins an infusion of packed The correct answer is 4. The patietn is experiencing a transfusion
RBCs, the patient complains of chills, chest and back pain, and reaction. The immediate nursing action is to stop the transfusion
nausea. His face is flushed, and he's anxious. Which is the and maintain a patent IV line. The other options may be indicated
priority nursing action? but aren't the priority in this case.
1. Administering antihistamines STAT for an allergic reaction.
2. Notifying the physician of a possible transfusion reaction.
3. Obtaining a urine and serum specimen to send to the lab
immediately.
4. Stopping hte transfusion and maintaining a patent IV catheter."
5. "A month after receiving a blood Correct: B
transfusion an immunocompromised GVHD occurs when white blood cells in donor blood attack the tissues of an
male patient develops fever, liver immunocompromised recipient. This process can occur within a month of the transfusion.
abnormalities, a rash, and diarrhea. Options 1 and 4 may be a thought, but the nurse must remember that immunocompromised
The nurse would suspect this patient transfusion recipients are at risk for GVHD
has:
a. Nothing related to the blood
transfusion
b. Graft-versus-host disease (GVHD)
c. Myelosuppression
d. An allergic response to a recent
medication"
6. ". A unit of packed red blood cells has "F, D, B, A, C, E
been prescribed for a client with low - The nurse would first verify the physician's order for the blood transfusion and ensure that
hemoglobin and hematocrit levels. The the client has been informed about the procedure and has signed an informed consent. Once
nurse notifies the blood bank of the this has been done, the nurse would ensure that at least an 18- or 19-gauge intravenous
order, and a blood specimen is drawn needle is inserted into the client. Blood has a thicker and stickier consistency than
from the client for typing and cross- intravenous solutions and using an 18- or 19-gauge catheter ensures that the bore of the
matching. The nurse receives a catheter is large enough to prevent damage to the blood cells. Next, the blood is obtained
telephone call from the blood bank and from the blood bank, once the nurse is sure that the client has been informed and has an
is informed that he unit of blood is adequate access for administering the blood. Once the blood has been obtained, two
ready for administration. Arrange the registered nurses, or one registered and a licensed practical nurse (depending on agency
actions in order of priority that the policy), must together check the label on the blood product against the client's identification
nurse should take to administer the number, blood group, and complete name. This minimizes the risk of error in checking
blood. (Letter A is the first and letter F information on the blood bag and thereby minimizes the risk of harm or injury to the client.
is the last action.) The nurse should measure vital signs and assess lung sounds and then hang the
a) hang the bag of blood transfusion."`
b) obtain the unit of blood from the bank
c) ensure that an informed consent has
been signed
d) verify the physician's order for the
blood transfusion
e) insert an 18 or 19-gauge IV catheter
into the client
f) ask a licensed nurse to assist in
confirming blood compatibility and
verifying client identity."
7. "Before starting a transfusion of packed Correct B
red blood cells for an anemic patient, Patients who are likely to have a transfusion reaction will more often exhibit signs within the
the nurse would arrange for a peer to first 15 minutes that the blood is infusing
monitor his or her other assigned
patients for how many minutes when
the nurse begins the transfusion?
A. 5 minutes
B. 15 minutes
C. 60 minutes
D. 30 minutes"
8. A child with beta-thalassemia is Correct answer: 3. Deferoxamine (Desferal) Rationale: Beta-Thalassemia is an autosomal
receiving long-term blood transfusion recessive disorder characterized by the reduced production of one of the globin chains in the
therapy for the treatment of this synthesis of hemoglobin (both parents must be carriers to produce a child with Beta-
disorder. Chelation therapy is Thalassemia major). The major complication of long-term transfusion therapy is
prescribed to prevent organ damage hemosiderosis. To prevent organ damage from too much iron, chelation therapy with either
from the presence of too much iron in deferasirox (Exjade) or deferoxamine (Desferal) may be prescribed. Deferoxamine is
the body as a result of the transfusions. classified as an antidote for acute iron toxicity. Dalteparin is an anticoagulant used as
Which of the following medications prophylaxis for postoperative DVT. Meropenem is an antibiotic. Metoprolol is a Beta-blocker
would the nurse anticipate to be used to treat HTN.
prescribed in chelation therapy?
1. Meopenem (Merrem) 2. Metoprolol
(Toprol-XL) 3. Deferoxamine (Desferal)
4. Dalteparin sodium (Fragmin)
9. The client has a hematocrit of 22.3% and a hemoglobin Correct: 1, 3, 4
of 7.7 mg/dL. The HCP hasordered two (2) units of
packed red blood cells to be transfused. Which
interventionsshould the nurse implement? Select all
that apply
1. Obtain a signed consent.
2.Initiate a 22-gauge IV.
3.Assess the client's lungs.
4.Check for allergies.
5.Hang a keep-open IV of D5W
10. A client receiving a transfusion of packed red blood A, septicemia occurs with transfusion of blood contaminated with
cells begins to vomit. The client's blood pressure is microorganisms. Signs include chills, fever, vomiting, diarrhea, hypotension,
90/50 from a baseline of 125/78. Temp is 100.8 from and development of shock. Hyerkalemia causes weakness, paresthesia,
baseline 99.2 orally. The nurse determines patient is abdominal cramps, diarrhea, and dysrythmias. Circulatory overload causes
experiencing which complication with blood cough, dyspnea, chest pain, wheezing, tachycardia, and hypertension.
transfusion? a. septicemia B. hyperkalemia. c. Delayed transfusion reaction can occer days or weeks after transfuison.
circulatory overload. D. Delayed tranfusion reaction. Signs include fever, mild jaundice, and a decrease hematocrit level.
11. "Complications of transfusions that can be decreased Correct: D
by the use of leukocyte depletion or reduction of RBC Rationale: Infectious viruses, such as human immunodeficiency virus (HIV),
transfusion are human herpesvirus, hepatitis B and C type 6 (HSV-6), Epstein-Barr virus
a. chills and hemolysis. (EBV), human T-cell leukemia virus type 1 (HTLV-1), and cytomegalovirus
b. leukostasis and neutrophilia. (CMV), and other agents, such as the agent that causes malaria, can be
c. fluid overload and pulmonary edema. transmitted by blood transfusion. Leukocyte-reduced blood products
d. transmission of cytomegalovirus and fever. drastically reduce the risk of blood transfusion-associated viral infections,
including CMV.
12. "Cris asks the nurse whether all donor blood products Correct: A
are cross-matched with the recipient to prevent a Red blood cells contain antigens and antibodies that must be matched
transfusion reaction. Which of the following always between donor and recipient. The blood products in options 2-4 do not
require cross-matching? contain red cells. Thus, they require no cross-match.
a. packed red blood cells
b. platelets
c. plasma
d. granulocytes"
13. During a blood transfusion a client develops chills and B) stop the transfusion because chills, headache, and nausea are all signs
a headache, what is the priority nursing action of transfusion reaction
A) cover the client B) stop the transfusion at once C)
notify the physician immediately D) decrease the rate
of blood infusion
14. "Following surgery, the client requires a blood Correct A
transfusion. The main reason the nurse wants to Hanging for a longer four hours creates an increased risk of sepsis, which is
complete the unit transfusion within a four-hour period why the nurse wants to complete the unit transfusion in less than four hours.
that blood: The remaining items are not likely to happen.
"A. Hanging for a longer four hours creates an
increased risk of sepsis
B. May clot in the bag
C. May evaporate
D. May not clot in the recipient after this time period
15. "(from nclex reviewers) The nurse is aware
that the following solutions is routinely used
to
flush an IV device before and after the
administration of blood to a
patient is:
"a. 0.9 percent sodium chloride
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."

b. 5 percent dextrose in water solution

c. Sterile water

d. Heparin sodium
16. Halfway through the administration of blood, Correct A
the female client complains of lumbar pain. The blood must be stopped at once, and then normal saline should be infused to keep
After stopping the infusion Nurse Hazel the line patent and maintain blood volume.
should:
a. Increase the flow of normal saline
b. Assess the pain further
c. Notify the blood bank
d. Obtain vital signs."
17. A new RN is preparing to administer packed Correct: C
red blood cells (PRBCs) to a client whose ANSWER C - Normal saline, an isotonic solution, should be used when priming the IV
anemia was caused by blood loss after line to avoid causing hemolysis of RBCs. Ideally, blood products should be infused as
surgery. Which action by the new RN requires soon as possible after they are obtained; however, a 20-minute delay would not be
that you, as charge nurse, intervene unsafe. Large-gauge IV catheters are preferable for blood administration; if a smaller
immediately? catheter must be used, normal saline may be used to dilute the RBCs. Although it is
"a. The new RN waits 20 minutes after appropriate to instruct clients to notify the nurse if symptoms of a transfusion
obtaining the PRBCs before starting the reaction such as shortness of breath or chest pain occur, it will cause unnecessary
infusion. anxiety to indicate that a serious reaction is likely to occur. Focus: Prioritization
b. The new RN starts an intravenous line for
the transfusion using a 22-gauge catheter.
c. The new RN primes the transfusion set
using 5% dextrose in lactated Ringer's
solution.
d. The new RN tells the client that the PRBCs
may cause a serious transfusion reaction."
18. A nurse check a unit of blood received from Correct: A
the blood bank and notes the presence of gas The nurse should return the blood to the blood bank because the gas bubbles in the
bubbles in the bag. Which should the nurse bag indicate possible contamination. If the nurse were going to administer the blood,
implement? the nurse would use filter tubing to trap the particulate matter. Although normal saline
A. Return the bag to the blood bank. B. Infuse can be infused concurrently with the blood, NS or any other substance should never
the blood using the filter tubing. C. Add 10ml be added to the blood in a blood bag. The blood should not be agitated this can harm
of NS to the bag. D. Agitate the bag to mix the RBCs.
contents gently.
19. The nurse enters a client's room to assess the Correct: 3
client, who began receiving a blood With fluid overload, the client has the presence of crackles in addition to dyspnea. An
transfusion 45 minutes earlier, and notes that allergic reation, a type of blood transfusion reaction, would produce symptoms such
the client is flushed and dyspneic. On as flushing, dyspnea, itching, and a generalized rash. Hypovolemia is not
assessment, the nurse auscultates the complication of blood transfusions. With bacteriemia, the client would have fever, a
presence of crackles in the lung bases. The symptom not presented.
nurse determines that this client most likely
is experiencing which complication of blood
transfusion therapy?
1) Bacteriemia. 2) Hypovolemia. 3) Fluid
overload 4) Transfusion reaction
20. The nurse has obtained a unit of blood from Correct Answer A
the blood bank and has checked the blood Change in vital signs during the transfusion from the baseline may indicate that a
bag properly with another nurse. Just before transfusion reaction is occuring. This is why nurse assesses vital signs before the
the beginning transfusion, the nurse procedure and again after 15 mintues. The other options do not identify assessment
assessess which of the following items? that are required just before beginning a transfusion.
A. Vital signs B. Skin Color C. Urine ouput D.
Latest hematocrit level.
21. A nurse has received a prescription to Correct: 1
transfuse a client with a unit of packed red Asking the client about personal experience with tranfusion therapy provides a good
blood cells. Before explaining the procedure starting point for client teaching about this procedure. Options 3 & 4 are not helpful
to the client, the nurse asks which initial because they may elicit a fearful response from the client. Although determining
questions? whether the client knows the reason for the transfusion is important, option 2 is not an
1. Have you ever had a transfusion before? appropriate statement in terms of eliciting information from the client regarding an
2. Why do you think that you need the understanding of the need for the transfusion.
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?
22. The nurse is caring for a 70-year-old client Answer A is correct. The client is exhibiting symptoms of fluid volume excess; slowing
with hypovolemia who is receiving a blood the rate is the proper action. The nurse would not stop the infusion of blood, as in
transfusion. Assessment findings reveal answer C, and answers B and D would not help.
crackles on chest auscultation and distended
neck veins. What is the nurse's initial
action?
A. Slow the transfusion.
B. Document the finding as the only action.
C. Stop the blood transfusion and turn on the
normal saline.
D. Assess the client's pupils."
23. The nurse is preparing to administer a blood Correct C
transfusion of PRBCs. The correct solution to The correct answer is normal saline. Normal saline is the only solution used to flush the
use to flush the tubing when administering a tubing during a blood transfusion. The other solutions listed aren't indicated and may
blood transfusion is: hemolyze the RBCs.
A. 5% dextrose in water (D5W). B. Lactated
Ringer's solution (LR). C. 0.9% NaCl (normal
saline) solution D. Plasmalyte-A
24. The nurse is working in a blood bank facility Correct 3
procuring units of blood from donors. Which "1. Oral surgeries are associated with transientbacteremia, and the client cannot
client would not be a candidate to donate donate for 72hours after an oral surgery.2.The client cannot donate blood following
blood? ubella immunizations for one (1) month.
1.The client who had wisdom teeth removed 3. CORRECT
a week ago.2.The nursing student who The client cannot donate blood for 6months after a pregnancy because of thenutritional
received a measles immunization 2 months demands on the mother.
ago.3. The mother with a six (6)-week-old 4.Recent allergic reactions prevent donationbecause passive transference of
newborn.4.The client who developed an hypersensitiv-ity can occur. This client has an allergy thatdeveloped during childhood"
allergy to aspirin in childhood
25. The nurse who is about to give a blood Correct A - no rationale
transfusion knows that blood cells start to
deteriorate after a certain period of time.
Which of the following itens is important to
check regarding the age of blood cells before
the transfusion is begun?
A. Expiration date
B. Presence of clots
C. Blood group and type
D. Blood identification number"
26. "Packed red blood cells have been prescribed
for a client with a low hemoglobin and
hematocrit levels. The nurse takes the client's
temperature before hanging the blood
transfusion and records 100.6 degrees orally.
Which of the following is the appropriate
nursing action?
A) Begin the transfusion as prescribed
B) Delay hanging blood and notify the physician
C) Administer an antihistamine and begin the
transfusion
D) Administer two tablets of Tylenol and begin
the transfusion"
27. "The client is admitted to the ED after a MVA.
The nurse notes profuse bleeding from a right-
sided abdominal injury. Which intervention
should the nurse implement first?
1.) Type and crossmatch for RBCs immediately
(STAT). 2.) Initiate an IV with an 18-gauge
needle and hang normal saline. 3.) Have the
client sign a consent for an exploratory
laparotomy. 4.) Notify the significant other of
the client's admission.
28. "The client with O+ blood is in need of an
emergency transfusion but the lab does not
have any O+ blood available. Which potential
unit of blood could be given to the client?
"1. 0- unit
2. A+ unit
3. B+ unit
4. Any Rh+ unit"
29. "The nurse and unlicensed nursing assistant
are caring for clients on an oncology floor.
Which nursing task would be delegated to the
unlicensed nursing assistant?
"1. Assess the urine output on a client who has
had a blood transfusion reaction.
2. Take the first 15 minutes of vital signs on a
client receiving a unit of PRBCs.
3. Auscultate the lung sounds of a client prior
to a transfusion.
4. Assist a client who received ten (10) units of
platelets in brushing teeth.
"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."
*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 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."
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."
30. "The nurse determines that a client is having a
transfusion reaction. After the nurse stops the
transfusion, which action should immediately
be taken next?
1. remove the intravenous 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"
31. "The nurse is administering packed red blood
cells (PRBCs) to a client. The nurse should
first:
"1. Discontinue the I.V. catheter if a blood
transfusion reaction occurs.
2. Administer the PRBCs through a
percutaneously inserted central
catheter line with a 20-gauge needle. 3. Flush
PRBCs with 5% dextrose
and 0.45% normal saline solution. 4. Stay with
the client during the
first 15 minutes of infusion.
32. "The nurse is caring for a patient who is to
receive a transfusion of two units of packed red
blood cells. After obtaining the first unit from
the blood bank, the nurse would ask which of
the following health team members in the
nurses' station to assist in checking the unit
before adiminstration?
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: 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.
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.

A: Unit Secretary
B: A Phlebotomist
C: A Physician's Assistant
D: Another Registered Nurse
33. "The nurse is preparing to initiate a blood Answer: B "Rationale: A blood infusion must be administered via a
transfusion. The client has a peripheral separate IV line. The other responses indicate to the client their request is
intravenous infusion in their left arm that the being considered"
physician has ordered not be slowed or rate
reduced. The nurse prepares to start another
line in the right arm. The client asks the nurse
to use the existing site to avoid the trauma of
having another line started. Which of the
following statements by the nurse is correct?
A. ""That will be fine""
B. "I will need to infuse the blood through a
separate IV line."
C. "I will let the physician know about your
preferences."
D. "We will need to assess the line before I can
make a determination about your request.""
34. "The nurse receives a physician's order to transfuse fresh frozen plasma Correct A
to a patient suffering from an acute blood loss. Which of the following "The fresh frozen plasma should be administered as
procedures is most appropriate for infusing this blood product? rapidly as possible
A. Infuse the fresh frozen plasma as rapidly as the patient will tolerate. and should be used within 2 hours of thawing. Fresh
B. Hang the fresh frozen plasma as a piggyback to the primary IV solution. frozen plasma is
C. Infuse the fresh frozen plasma as a piggyback to a primary solution of infused using any straight-line infusion set. Any
normal saline. existing IV should be
D. Hand the fresh frozen plasma as a piggyback to a new bag of primary IV interrupted while the fresh frozen plasma is infused,
solution without KCl." unless a second IV
line has been started for the transfusion."
35. "The nurse understands that the client
with pernicious anemia will have which
distinguishing laboratory findings?
"a. Schilling's test, elevated
b. Intrinsic factor, absent.
c. Sedimentation rate, 16 mm/hour
d. RBCs 5.0 million
36. "The physician orders 2 units of packed
RBCs to be administered to the client. At
0600 the night shift nurse initiates the
first unit's transfusion before going off
shift. At 1000 the day shift nurse notes the
IV line has clotted off and the transfusion
has not been completed. The nursing
assessment revealed the transfusion was
only approximately 75% complete. Which
of the actions by the nurse is most
appropriate?
A. Advise the blood bank about the delay
for the next unit.
B. Restart another peripheral line with
0.9% NS and restart
the blood transfusion with the remaining
blood unit.
C. Discontinue the transfusion.
D. Document the amount infused thus far
and continue the transfusion."
37. "Which organ is at greatest risk due to the
effects of hemolytic anemia?
"A. Heart
B. Spleen
C. Kidney
D. Liver
38. "Which statement is the scientific
rationale for infusing a unit of blood in
less than four (4) hours?
"1. The blood will coagulate if left out of
the refrigerator for >four (4) hours.
2. The blood has the potential for bacterial
growth if allowed to infuse longer.
3. The blood components begin to break
down after four (4) hours.
4. The blood will not be affected; this is a
laboratory procedure."
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.
"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: 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 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."
39. "Which statement is the scientific
rationale for infusing a unit of blood in
less than four (4) hours?
(Med Surg Success)" "1. The blood will
coagulate if left out of the refrigerator for
longer than four(4)hours.
2. The blood has the potential for bacterial
growth if allowed to infuse longer.
3. The blood components begin to break
down after four (4) hours.
4. The blood will not be affected; this is a
laboratory procedure. "
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."