Blood Administration NCLEX Practice Questions and Answers

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. 3) Delay hanging the blood and notify the health care provider. 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? 1) "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?" 1) "Have you ever had a transfusion before?" 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. 00:49 01:14 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? 1) Septicemia 2) Hyperkalemia 3) Circulatory overload 4) Delayed transfusion reaction 1) Septicemia 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 keep-vein-open rate. 4) Obtain a culture of the tip of the catheter device removed from the client. 3) Run normal saline at a keep-vein-open rate. Rationale: If the nurse suspects a transfusion reaction, the nurse stops the transfusion and infuses normal saline at a keep-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 vent 2) Tinted tubing 3) An in-line filter 4) A microdrip chamber 3) An in-line filter 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 macrodrip, not microdrip, 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 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. An elevated temperature would decline to normal after infusion of granulocytes if those cells were instrumental in fighting infection in the body. The nurse has obtained a unit of blood from the blood bank and has checked the blood bag properly with another nurse. Just before beginning the transfusion, the nurse should assess which PRIORITY item? 1) Vital signs 2) Skin color 3) Urine output 4) Latest hematocrit level 1) Vital signs Rationale: A change in vital signs during the transfusion from baseline may indicate that a transfusion reaction is occurring. This is why the nurse assesses vital signs BEFORE the procedure and again after the first 15 minutes. The other options do not identify assessments that are a priority just before beginning a transfusion. The nurse has just received a prescription to transfuse a unit of packed red blood cells for an assigned client. Approximately how long will the nurse need to stay with the client to ensure that a transfusion reaction is not occurring? 1) 5 minutes 2) 15 mintues 3) 30 minutes 4) 45 mintues 2) 15 mintues Rationale: The nurse must remain with the client for the first 15 minutes of a transfusion, which is usually when a transfusion reaction may occur. This enables the nurse to detect a reaction and intervene quickly. Following infusion of a unit of packed red blood cells, the client has developed new onset of tachycardia, bounding pulses, crackles, and wheezes. Which action should the nurse implement FIRST? 1) Maintain bed rest with legs elevated 2) Place the client in high-Fowler's position 3) Increase the rate of infusion of intravenous fluids 4) Consult with the HCP regarding initiation of oxygen therapy. 2) Place the client in high-Fowler's position Rationale: New onset of tachycardia, bounding pulses, crackles and wheezes post-transfusion are evidence of fluid overload, a complication associated with blood transfusions. Placing the client in a high-Fowler's (upright) position will facilitate breathing. Measures that increase blood return to the heart, such as leg elevation and administration of intravenous fluids, should be avoided at this time. In addition, administration of fluids cannot be initiated without a prescription. Consulting with the HCP regarding administration of oxygen may be necessary, but positional changes take a short amount of time to do and should be initiated first. The nurse, listening to the morning report, learns that an assigned client received a unit of granulocytes the previous evening. The nurse makes a note to assess the results of which daily serum laboratory studies to assess the effectiveness of the transfusion? 1) Hematocrit level 2) Erythrocyte count 3) Hemoglobin level 4) White blood cell count 4) White blood cell count Rationale: The client who has neutropenia may receive a transfusion of granulocytes, or white blood cells. These clients often have severe infections and are unresponsive to antibiotic therapy. The nurse notes the results of follow-up white blood cell counts and differential to evaluate the effectiveness of the therapy. The nurse also continues to monitor the client for signs and symptoms of infection. Erythrocyte count and hemoglobin and hematocrit levels are determined after transfusion of packed red blood cells. A client is brought to the emergency department having experienced blood loss related to an arterial laceration. Fresh-frozen plasma is prescribed and transfused to replace fluid and blood loss. The nurse understands that which is the rationale for transfusing fresh-frozen plasma to this client? 1) To treat the loss of platelets 2) To promote rapid volume expansion 3) Because a transfusion must be done slowly 4) Because it will increase the hemoglobin and hematocrit levels 2) To promote rapid volume expansion Rationale: Fresh-frozen plasma is often used for volume expansion as a results of fluid and blood loss. It does not contain platelets, so it is not used to treat any type of low platelet count disorder. It is rich in clotting factors and can be thawed quickly and transfused quickly. It will not specifically increase the hemoglobin and hematocrit level. The nurse who is about to begin a blood transfusion knows that blood cells start to deteriorate after a certain period of time. Which item is important to check regarding the age of blood cells before the transfusion is begun? 1) Expiration date 2) Presence of clots 3) Blood group and type 4) Blood identification number 1) Expiration date Rationale: The nurse notes the expiration date on the unit of blood to ensure that the blood is fresh. Blood cells begin to deteriorate over time, so safe storage is usually limited to 35 days. Careful notation of the expiration date by the nurse is an essential part of the verification process before hanging a unit of blood. The nurse also notes the blood identification (unit) number, blood group and type, and client's name. The nurse also inspects the unit of blood for leaks, abnormal color, clots, and bubbles and returns the unit to the blood bank if clots are noted.