NURS MED SURG II EXAM STUDY GUIDE 2022/2023
UPDATE GRADED A+
1. Safe administration of a blood transfusion would require which assessments and
interventions by the nurse?
-Verify TPC: Right blood type, patient, component
-Verified by Two nurses
*Both nurses need to be present when the blood is hung, but not for the first 15 minutes, just
one nurse.
What are both nurses checking and documenting: PLET Patient
identification
Label on the unit of the blood
Expiration date
Transfusion tag attached to the unit
-Check ABO, must be ABO and Rh compatible! Check expiration date, consent for blood
transfusion is signed
-Assess baseline vital signs so that you can note for any changes after you start the
transfusion. During the transfusion, nurse must take VS periodically based on facility protocol:
Assess lung sounds-so you can note changes that occur during transfusion.
-Assess for good kidney and cardiovascular function prior to transfusion.
-Assess lab data, evaluate input and output
-Evaluate the IV site, gauge of the needle: For Rapid blood infusion or multiple
transfusions-use 18 inch gauge needle as opposed to 20 inch (normal infusion).
Anything smaller than 20-inch needle increases the risk for hemolysis.
-Use good hand hygiene and standardized precaution b/c you’re dealing w/ blood components.
Use y-type filtered blood set = 2 drip chambers, spike one port w/ NS-IT MUST BE NS,
prime tube w/ NS to saturate the filter. Attach RBCs to second port.
Once you hang the blood, turn off NS and turn on blood component.
-Blood products are always hung w/ NS using 3-way tubing and filter
-Begin slowly with 10 drops/min: enough to notice an allergic rxn, w/ enough
time to d/c tx and treat rxn w/out any dire consequences.
-Monitor for first 15 minutes after start of transfusion to ensure no rxn
,NURS MED SURG II EXAM STUDY GUIDE 2022/2023
UPDATE GRADED A+
occurs
,NURS MED SURG II EXAM STUDY GUIDE 2022/2023
UPDATE GRADED A+
-Infusion must begin w/in 15-30 minutes after removal from blood bank
-Infuse w/in 4 hours to reduce risk of bacterial contamination (growth): can be
hung by gravity or pump usually by pump due to 4 hr limit!
-Change tubing w/ each unit or per hospital policy
-If the transfusion is a lot, the blood may need to be warm to prevent hypothermia
*For patients w/ Iga (antigen A) deficiency
2. Who can administer transfusions? Legal requirements?
A nurse can administer transfusion, legal requirement require that two nurses verify
ABO compatibility (that the donor blood is the right match, right patient, and right
component), nurses check that the labeling is correct as well, and check that the blood has
not expired.
Legal requirements: Signed consent from patient for blood transfusion.
3. What signs and symptoms indicate the possibility of a transfusion reaction? a.
Immediate intervention indicated? (9)
Transfusion rxn protocol
1. Stop transfusion, notify MD immediately
2. Disconnect transfusion, keep line open w/ normal saline
3. Repeat typing and culture of blood bag T & C
4. Draw blood for plasma Hgb, culture, and typing (H C T)
5. Collect and send urine for Hgb
6. Safety report: Urine sample, write very detailed progress notes, detail S&S,
lab values-electrolytes ABG! in the event that a rxn occurs
1. Acute hemolytic reaction: wrong blood type
S&S (7): Apprehension, dyspnea, hypotension, C-V collapse, fever, chills, back ache
(think kidney) CV/HAD/FC/BA
Interventions: Stop transfusion, keep vein open with normal saline (hydration), notify
physician
2. Risk for delayed hemolytic reaction: Asymptomatic, or fever or jaundice may
occur. Mild hemolysis 2-3 days post transfusion, HCT may drop 3-14 days after transfusion.
-NO tx necessary unless hemolysis is severe!
3. Febrile, non-hemolytic reaction: mild increase in temp ≥ 1 degree Celsius
S&S (3): Chills, shaking, rigor
Intervention: Stop transfusion, pre-medicate with acetaminophen in future
transfusions
4. Mild allergic reaction: S&S:
Hives, urticaria
, NURS MED SURG II EXAM STUDY GUIDE 2022/2023
UPDATE GRADED A+
Intervention: Stop transfusion, administer anti-histamine Resume
transfusion if symptoms abate
**if the pt is known to have rxns in future transfusions administer allergy med (Benadryl)
prior to transfusion.
5. Severe anaphylaxis
Interventions: Stop transfusion, administer anti-histamine (may be too late)
/steroids/vasopressors as needed
Pre-medicate with anti-histamine and steroids for future transfusion
Prevention: Autologous or well washed RBCs to prevent severe rxn
6. Volume overload:
Risk factors:
-Advanced age
-Low cardiac contractility (weak cardiac fxn, or HF)
Prevention- Infuse slowly
Diuretic before or between units (2 units of PRBCs, infuse slowly over 4 hrs,
give lasix) Infusion too fast or too much = too volume for patient’s CV status
S&S (5): CCTHD Cough, dyspnea (SOB), crackles, tachycardia, HTN
Interventions:, Stop transfusion, assess fluid status elevate head of bed, lower feet,
oxygenate, diuretics, morphine (meds as described),
7. Iron overload: Occurs with multiple or frequent transfusions
S&S: (VDH) Vomiting, diarrhea, hypotension
Intervention: Iron chelation therapy; defroxamine turns urine red as it takes iron out of
the body. Given IV or SubQ
Don’t know if these last 2 apply, but they are still risks associated w/ transfusion rxns
8. Risk for electrolyte imbalance: Sodium citrate is the preservative used in blood bags and
citrate binds calcium this can lead to a reduction in serum K, coagulopathy, tetany and cardiac
arrhythmias.
Unlikely to occur unless: Massive transfusion is necessary.
In event of acute hemorrhage or trauma, we must monitor ionized calcium and magnesium
and replace as needed
9. Risk for Hyperkalemia – Stored blood liberates potassium from the cell.
Check expiration date on blood products b/c once they pass the expiration
date, the increase in potassium is significant.
Monitor potassium
4. What measures decrease the possibility of sepsis associated with blood
transfusions?
-Improved donor testing-Donors screened for bacterial infections, parasites, and
creutzfeld-jakob
-Testing of the donor blood-blood testing of Hep. B, C, HIV
UPDATE GRADED A+
1. Safe administration of a blood transfusion would require which assessments and
interventions by the nurse?
-Verify TPC: Right blood type, patient, component
-Verified by Two nurses
*Both nurses need to be present when the blood is hung, but not for the first 15 minutes, just
one nurse.
What are both nurses checking and documenting: PLET Patient
identification
Label on the unit of the blood
Expiration date
Transfusion tag attached to the unit
-Check ABO, must be ABO and Rh compatible! Check expiration date, consent for blood
transfusion is signed
-Assess baseline vital signs so that you can note for any changes after you start the
transfusion. During the transfusion, nurse must take VS periodically based on facility protocol:
Assess lung sounds-so you can note changes that occur during transfusion.
-Assess for good kidney and cardiovascular function prior to transfusion.
-Assess lab data, evaluate input and output
-Evaluate the IV site, gauge of the needle: For Rapid blood infusion or multiple
transfusions-use 18 inch gauge needle as opposed to 20 inch (normal infusion).
Anything smaller than 20-inch needle increases the risk for hemolysis.
-Use good hand hygiene and standardized precaution b/c you’re dealing w/ blood components.
Use y-type filtered blood set = 2 drip chambers, spike one port w/ NS-IT MUST BE NS,
prime tube w/ NS to saturate the filter. Attach RBCs to second port.
Once you hang the blood, turn off NS and turn on blood component.
-Blood products are always hung w/ NS using 3-way tubing and filter
-Begin slowly with 10 drops/min: enough to notice an allergic rxn, w/ enough
time to d/c tx and treat rxn w/out any dire consequences.
-Monitor for first 15 minutes after start of transfusion to ensure no rxn
,NURS MED SURG II EXAM STUDY GUIDE 2022/2023
UPDATE GRADED A+
occurs
,NURS MED SURG II EXAM STUDY GUIDE 2022/2023
UPDATE GRADED A+
-Infusion must begin w/in 15-30 minutes after removal from blood bank
-Infuse w/in 4 hours to reduce risk of bacterial contamination (growth): can be
hung by gravity or pump usually by pump due to 4 hr limit!
-Change tubing w/ each unit or per hospital policy
-If the transfusion is a lot, the blood may need to be warm to prevent hypothermia
*For patients w/ Iga (antigen A) deficiency
2. Who can administer transfusions? Legal requirements?
A nurse can administer transfusion, legal requirement require that two nurses verify
ABO compatibility (that the donor blood is the right match, right patient, and right
component), nurses check that the labeling is correct as well, and check that the blood has
not expired.
Legal requirements: Signed consent from patient for blood transfusion.
3. What signs and symptoms indicate the possibility of a transfusion reaction? a.
Immediate intervention indicated? (9)
Transfusion rxn protocol
1. Stop transfusion, notify MD immediately
2. Disconnect transfusion, keep line open w/ normal saline
3. Repeat typing and culture of blood bag T & C
4. Draw blood for plasma Hgb, culture, and typing (H C T)
5. Collect and send urine for Hgb
6. Safety report: Urine sample, write very detailed progress notes, detail S&S,
lab values-electrolytes ABG! in the event that a rxn occurs
1. Acute hemolytic reaction: wrong blood type
S&S (7): Apprehension, dyspnea, hypotension, C-V collapse, fever, chills, back ache
(think kidney) CV/HAD/FC/BA
Interventions: Stop transfusion, keep vein open with normal saline (hydration), notify
physician
2. Risk for delayed hemolytic reaction: Asymptomatic, or fever or jaundice may
occur. Mild hemolysis 2-3 days post transfusion, HCT may drop 3-14 days after transfusion.
-NO tx necessary unless hemolysis is severe!
3. Febrile, non-hemolytic reaction: mild increase in temp ≥ 1 degree Celsius
S&S (3): Chills, shaking, rigor
Intervention: Stop transfusion, pre-medicate with acetaminophen in future
transfusions
4. Mild allergic reaction: S&S:
Hives, urticaria
, NURS MED SURG II EXAM STUDY GUIDE 2022/2023
UPDATE GRADED A+
Intervention: Stop transfusion, administer anti-histamine Resume
transfusion if symptoms abate
**if the pt is known to have rxns in future transfusions administer allergy med (Benadryl)
prior to transfusion.
5. Severe anaphylaxis
Interventions: Stop transfusion, administer anti-histamine (may be too late)
/steroids/vasopressors as needed
Pre-medicate with anti-histamine and steroids for future transfusion
Prevention: Autologous or well washed RBCs to prevent severe rxn
6. Volume overload:
Risk factors:
-Advanced age
-Low cardiac contractility (weak cardiac fxn, or HF)
Prevention- Infuse slowly
Diuretic before or between units (2 units of PRBCs, infuse slowly over 4 hrs,
give lasix) Infusion too fast or too much = too volume for patient’s CV status
S&S (5): CCTHD Cough, dyspnea (SOB), crackles, tachycardia, HTN
Interventions:, Stop transfusion, assess fluid status elevate head of bed, lower feet,
oxygenate, diuretics, morphine (meds as described),
7. Iron overload: Occurs with multiple or frequent transfusions
S&S: (VDH) Vomiting, diarrhea, hypotension
Intervention: Iron chelation therapy; defroxamine turns urine red as it takes iron out of
the body. Given IV or SubQ
Don’t know if these last 2 apply, but they are still risks associated w/ transfusion rxns
8. Risk for electrolyte imbalance: Sodium citrate is the preservative used in blood bags and
citrate binds calcium this can lead to a reduction in serum K, coagulopathy, tetany and cardiac
arrhythmias.
Unlikely to occur unless: Massive transfusion is necessary.
In event of acute hemorrhage or trauma, we must monitor ionized calcium and magnesium
and replace as needed
9. Risk for Hyperkalemia – Stored blood liberates potassium from the cell.
Check expiration date on blood products b/c once they pass the expiration
date, the increase in potassium is significant.
Monitor potassium
4. What measures decrease the possibility of sepsis associated with blood
transfusions?
-Improved donor testing-Donors screened for bacterial infections, parasites, and
creutzfeld-jakob
-Testing of the donor blood-blood testing of Hep. B, C, HIV
