Blood Transfusion NCLEX Exam with complete solution

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Blood Transfusion NCLEX Exam with complete solution The nurse has obtained a unit of blood from the blood bank and has checked the blood bag properly with another nurse. Just before the beginning t ... ransfusion, the nurse assesses which of the following items? A. Vital signs B. Skin Color C. Urine output D. Latest hematocrit level. - ANSWER Correct Answer A Change in vital signs during the transfusion from the baseline may indicate that a transfusion reaction is occurring. This is why nurse assesses vital signs before the procedure and again after 15 minutes. The other options do not identify assessment that are required just before beginning a transfusion. "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." - ANSWER "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." "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" - ANSWER "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." About ten minutes after the nurse begins an infusion of packed RBCs, the patient complains of chills, chest and back pain, and nausea. His face is flushed, and he's anxious. Which is the priority nursing action? 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." - ANSWER 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. "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. - ANSWER 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. ". A unit of packed red blood cells has been prescribed for a client with low hemoglobin and hematocrit levels. The nurse notifies the blood bank of the order, and a blood specimen is drawn from the client for typing and cross-matching. The nurse receives a telephone call from the blood bank and is informed that he unit of blood is ready for administration. Arrange the actions in order of priority that the nurse should take to administer the blood. (Letter A is the first and letter F is the last action.) a) hang the bag of blood 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." - ANSWER "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."` The nurse enters a client's room to assess the client, who began receiving a blood transfusion 45 minutes earlier, and notes that the client is flushed and dyspneic. On assessment, the nurse auscultates the presence of crackles in the lung bases. The 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 - ANSWER 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. "Before starting a transfusion of packed red blood cells for an anemic patient, the nurse would arrange for a peer to 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" - ANSWER 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 [Show More]

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