Packed red blood cells have been prescribed for a client with low hemoglobin and hematocrit levels. The nurse takes the client's temperature before hanging the blood transfusion and records 100.6 F orally. Which action s
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Packed red blood cells have been prescribed for a client with low hemoglobin and hematocrit levels. The nurse takes the client's temperature before hanging the blood transfusion and records 100.6 F orally. Which action should the nurse take?
1) Begin the transfusion as prescribed.
2) Administer an antihistamine and begin the transfusion.
3) Delay hanging the blood and notify the health care provider.
4) Administer two tablets of acetaminophen (Tylenol) and begin the transfusion.
Rationale:
If the client has a temperature higher than 100 F, the unit of blood should not be hung until the HCP is notified and has the opportunity to give further prescriptions. The HCP likely will prescribe that the blood be administered regardless of the temperature, but the decision is not within the nurse's scope of practice to make. The nurse needs an HCP's prescription to administer medications to the client.
The nurse has received a prescription to transfuse a client with a unit of packed red blood cells. Before explaining the procedure to the client, the nurse should ask which INITIAL question?
"Have you ever had a transfusion before?"
2) "Why do you think that you need the 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?"
Rationale:
Asking the client about personal experience with transfusion therapy provides a good starting point for client teaching about this procedure. Questioning about previous history of shock and knowledge of complications and risks of transfusion 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, it is not an appropriate statement in terms of eliciting information from the client regarding an understanding of the need for the transfusion.
A client receiving a transfusion of packed red blood cells (PRBCs) begins to vomit. The client's blood pressure is 90/50 from a baseline of 125/78. The client's temperature is 100.8F orally from a baseline of 99.2F orally. The nurse determines that the client may be experiencing which complication of a blood transfusion?
Septicemia
2) Hyperkalemia
3) Circulatory overload
4) Delayed transfusion reaction
Rationale:
Septicemia occurs with the transfusion of blood contaminated with microorganisms. Signs include CHILLS, FEVER, VOMITING, DIARRHEA, HYPOTENSION, and the development of SHOCK.
Hyperkalemia causes weakness, paresthesias, abdominal cramps, diarrhea, and dysrhythmias.
Circulatory overload causes cough, dyspnea, chest pain, wheezing, tachycardia, and hypertension.
A delayed transfusion reaction can occur days to years after a transfusion. Signs include fever, mild jaundice, and a decreased hematocrit level.
The nurse determines that a client is having a transfusion reaction. After the nurse stops the transfusion, which action should be taken NEXT?
1) Remove the intravenous (IV) line.
2) Run a solution of 5% dextrose in water.
3) Run normal saline at a deep-vein-open rate.
4) Obtain a culture of the tip of the catheter device removed from the client.
Rationale:
If the nurse suspects a transfusion reaction, the nurse stops the transfusion and infuses normal saline at a deep-vein-open rate pending further health care provider 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 reactions, is suspected.
Normal saline is the solution of choice over solutions containing dextrose because saline does not cause red blood cells to clump.
The nurse has just received a unit of packed red blood cells from the blood bank for transfusion to an assigned client. The nurse is careful to select tubing especially made for blood products, knowing that this tubing is manufactured with which item?
1) An air vents
2) Tinted tubing
3) An in-line filter
4) A micro drip chambers
Rationale:
The tubing used for blood administration has an in-line filter. The filter helps ensure that any particles larger than the size of the filter are caught in the filter and are not infused into the client.
Tinted tubing is incorrect because blood does not need to be protected from light.
The tubing should be macro drip, not micro drip, to allow blood to flow freely through the drip chamber.
An air vent is unnecessary because the blood bag is not made of glass.
The client has received a transfusion of platelets. The nurse evaluates that the client is benefiting most from this therapy if the client exhibits which finding?
1) Increased hematocrit level
2) Increased hemoglobin level
3) Decline of elevated temperature to normal
4) Decreased oozing of blood from puncture sites and gums
Rationale:
Platelets are necessary for proper blood clotting. The client with insufficient platelets may exhibit frank bleeding or oozing of blood from puncture sites, wounds, and mucous membranes.
Increased hemoglobin and hematocrit levels would occur when the client has received a transfusion of red blood cells.
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