Professional Documents
Culture Documents
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 "Correct Answer B: If the client has a temperature higher than 100 degrees, the unit
for a client with a low hemoglobin and of blood should not be hung until the physician is notified and has the opportunity to
hematocrit levels. The nurse takes the client's give further prescriptions. The physician will likely prescribe that the blood be
temperature before hanging the blood administered regardless of the temperature, but the decision is not within the
transfusion and records 100.6 degrees orally. nurses's scope of practice to make. The nurse needs a physician's prescription to
Which of the following is the appropriate administer medications to the client.
nursing action? Options A, C, and D can all be excluded as they indicate beginning the transfusion."
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. *2.) The first action in a situation in which the nurse suspects the client has a fluid
The nurse notes profuse bleeding from a right- volume loss is to replace the volume as quickly as possible (CORRECT). 1.) This
sided abdominal injury. Which intervention should be done, but the client requires the IV fluids first because they are at risk for
should the nurse implement first? shock (omit #1). 3.)The client will probably need to have surgery to correct the
1.) Type and crossmatch for RBCs immediately source of the bleeding, but stabilizing the client with fluid resuscitation is first
(STAT). 2.) Initiate an IV with an 18-gauge priority (omit #3). 4.) This is the last thing on this list in order of priority (omit #4).
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 "Correct answer: Answer 1.
emergency transfusion but the lab does not
have any O+ blood available. Which potential 1. O- negative blood is considered the universal donor because it does not contain
unit of blood could be given to the client? the antigens A, B, or Rh. (AB+
is considered the universal recipient because a person with this blood type has all
"1. 0- unit the anti-gens on the blood).
2. A+ unit
3. B+ unit 2.A+ blood contains the antigen A that the client will react to, causing the
4. Any Rh+ unit" 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."
29. "The nurse and unlicensed nursing assistant Correct: 4
are caring for clients on an oncology floor. "1. Unlicensed nursing assistants cannot assess. The nurse cannot delegate
Which nursing task would be delegated to the assessment.
unlicensed nursing assistant? 2. The likelihood of a reaction is the greatest
"1. Assess the urine output on a client who has during the first 15 minutes of a transfusion.The nurse should never leave the client
had a blood transfusion reaction. until after this time. The nurse should take and assess the vital signs during this
2. Take the first 15 minutes of vital signs on a time.
client receiving a unit of PRBCs. 3. Auscultation of the lung sounds and administering blood based on this information
3. Auscultate the lung sounds of a client prior are the
to a transfusion. nurse's responsibility. Any action requiring nursing judgment cannot be delegated.
4. Assist a client who received ten (10) units of 4. The unlicensed nursing assistant can assist a client to brush the teeth.
platelets in brushing 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 Correct 3
transfusion reaction. After the nurse stops the If the nurse suspects a transfusion reaction, the nurse stops the transfusion and
transfusion, which action should immediately infuses normal saline at a keep-vein-open rate pending further physician
be taken next? prescriptions. This maintains a patent IV access line and aids in maintaining the
1. remove the intravenous line client's intravascular volume. The nurse would not remove the IV line because then
2. run a solution of 5% dextrose in water there would be no IV access route. Obtaining a culture of the tip of the catheter
3.run normal saline at a keep-vein-open rate device removed from the client is incorrect. First the catheter should not be
4. obtain a culture of the tip of the catheter removed. Second, cultures are performed when infection, not transfusion reaction,
device removed from the client" is suspected. Normal saline is the solution of choice over solutions containing
dextrose because saline does not cause red blood cells to clump.
31. "The nurse is administering packed red blood Correct: 4
cells (PRBCs) to a client. The nurse should The most likely time for a blood transfusion reaction to occur is during the first 15
first: minutes or first 50 mL of the infusion. If a blood transfusion reaction does occur, it
"1. Discontinue the I.V. catheter if a blood is imperative to keep an established I.V. line so that medication can be administered
transfusion reaction occurs. to prevent or treat cardiovascular collapse in case of anaphylaxis. PRBCs should be
2. Administer the PRBCs through a administered through a 19-gauge or larger needle; a peripherally inserted central
percutaneously inserted central catheter line is not recommended, in order to avoid a slow flow. RBCs will hemolyze
catheter line with a 20-gauge needle. 3. Flush in dextrose or lactated Ringer's solution and should be infused with only normal
PRBCs with 5% dextrose saline solution.
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 Correct: D
receive a transfusion of two units of packed red Before hanging a transfusion, the registered nurse must check the unit with
blood cells. After obtaining the first unit from ANOTHER RN or with a licensed practical (vocational) nurse, depending on agency
the blood bank, the nurse would ask which of policy. Checking blood products is not in the unit secretary's or phlebotimist's scope
the following health team members in the of practice. The physician assistant is not another RN or licensed practical nurse.
nurses' station to assist in checking the unit
before adiminstration?
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 Correct: B
with pernicious anemia will have which ANSWER B. The defining characteristic of pernicious anemia, a megaloblastic anemia, is
distinguishing laboratory findings? lack of the intrinsic factor, which results from atrophy of the stomach wall. Without the
"a. Schilling's test, elevated intrinsic factor, vitamin B12 cannot be absorbed in the small intestines, and folic acid
b. Intrinsic factor, absent. needs vitamin B12 for DNA synthesis of RBCs. The gastric analysis was done to
c. Sedimentation rate, 16 mm/hour determine the primary cause of the anemia. An elevated excretion of the injected
d. RBCs 5.0 million 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.
36. "The physician orders 2 units of packed "Answer C
RBCs to be administered to the client. At Rationale: A unit of blood should be administered
0600 the night shift nurse initiates the within a 4 hour period of time. The nurse should discontinue the
first unit's transfusion before going off transfusion, document the findings and notify the blood bank. The
shift. At 1000 the day shift nurse notes the agency policy will need to be followed concerning the documentation
IV line has clotted off and the transfusion process and notification of appropriate personnel. Continuing the
has not been completed. The nursing transfusion with the "open" unit will expose the client to an increase
assessment revealed the transfusion was risk of injury."
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 Correct: C
effects of hemolytic anemia? For all causes of hemolysis, a major focus of treatment is to maintain renal function.
"A. Heart When RBCs are hemolyzed, the hemoglobin molecule is released and filtered by the
B. Spleen kidneys. The accumulation of hemoglobin molecules can obstruct the renal tubules and
C. Kidney lead to acute tubular necrosis
D. Liver
38. "Which statement is the scientific Correct 2
rationale for infusing a unit of blood in "1. Blood will coagulate if left out for an extended period of, but blood is stored with a
less than four (4) hours? preservative that prevents this and prolongs the life of the blood.
"1. The blood will coagulate if left out of 2. (CORRECT). Blood is a medium for bacterial growth, and any bacteria contaminating the
the refrigerator for >four (4) hours. unit will begin to grow if left outside of a controlled refrigerated temperature for longer than
2. The blood has the potential for bacterial four (4) hours, placing the client at risk for septicemia.
growth if allowed to infuse longer. 3. Blood components are stable and do not break down after four (4) hours.
3. The blood components begin to break 4. These are standard nursing and laboratory procedures to prevent the complication of
down after four (4) hours. septicemia."
4. The blood will not be affected; this is a
laboratory procedure."
39. "Which statement is the scientific Correct: 2
rationale for infusing a unit of blood in "1,-Blood will coagulate if left out for an extended period, but blood is stored with a
less than four (4) hours? preservative that prevents this and prolongs the life of the blood.
(Med Surg Success)" "1. The blood will
coagulate if left out of the refrigerator for 2.-Blood is a medium for bacterial growth, and any bacteria contaminating the unit will
longer than four(4)hours. begin to grow if left outside of a con- trolled refrigerated temperature for longer than four
2. The blood has the potential for bacterial (4) hours, placing the client at risk for septicemia.
growth if allowed to infuse longer. .
3. The blood components begin to break 3)Blood components are stable and do not break down at four
down after four (4) hours.
4. The blood will not be affected; this is a 4.)These are standard nursing and laboratory procedures to prevent the complication of
laboratory procedure. " septicemia."