Blood Transfusion NCLEX with correct
answers 2025
Thevnursevhasvobtainedvavunitvofvbloodvfromvthevbloodvbankvandvhasvcheckedvthevbloodvbagvprope
rlyvwithvanothervnurse.vJustvbeforevthevbeginningvtransfusion,vthevnursevassessesvwhichvofvthevfoll
owingvitems?
A.vVitalvsignsv
B.vSkinvColorv
C.vUrinevouputv
D.vLatestvhematocritvlevel.v-vcorrect-answersv-CorrectvAnswervAv
Changevinvvitalvsignsvduringvthevtransfusionvfromvthevbaselinevmayvindicatevthatvavtransfusionvrea
v
ctionvisvoccuring.vThisvisvwhyvnursevassessesvvitalvsignsvbeforevthevprocedurevandvagainvafterv15vmi
ntues.vThevothervoptionsvdovnotvidentifyvassessmentvthatvarevrequiredvjustvbeforevbeginningvavtra
nsfusion.
Thevphysicianvordersv2vunitsvofvpackedvRBCsvtovbevadministeredvtovthevclient.vAtv0600vthevnightvshi
ftvnursevinitiatesvthevfirstvunit'svtransfusionvbeforevgoingvoffvshift.vAtv1000vthevdayvshiftvnursevnote
svthevIVvlinevhasvclottedvoffvandvthevtransfusionvhasvnotvbeenvcompleted.vThevnursingvassessmentvr
evealedvthevtransfusionvwasvonlyvapproximatelyv75%vcomplete.vWhichvofvthevactionsvbyvthevnurse
visvmostvappropriate?
,A.vAdvisevthevbloodvbankvaboutvthevdelayvforvthevnextvunit.
B.vRestartvanothervperipheralvlinevwithv0.9%vNSvandvrestart
thevbloodvtransfusionvwithvthevremainingvbloodvunit.
C.vDiscontinuevthevtransfusion.
D.vDocumentvthevamountvinfusedvthusvfarvandvcontinuevthevtransfusion.v-vcorrect-answersv-
AnswervC
Rationale:vAvunitvofvbloodvshouldvbevadministered
v withinvav4vhourvperiodvofvtime.vThevnursevshouldvdiscontinuevthev
transfusion,vdocumentvthevfindingsvandvnotifyvthevbloodvbank.vThev
agencyvpolicyvwillvneedvtovbevfollowedvconcerningvthevdocumentationv
processvandvnotificationvofvappropriatevpersonnel.vContinuingvthev
transfusionvwithvthev"open"vunitvwillvexposevthevclientvtovanvincreasev
riskvofvinjury.
ThevclientvwithvO+vbloodvisvinvneedvofvanvemergencyvtransfusionvbutvthevlabvdoesvnotvhavevanyvO+v
bloodvavailable.vWhichvpotentialvunitvofvbloodvcouldvbevgivenvtovthevclient?
1.v0-vunit
2.vA+vunit
3.vB+vunit
4.vAnyvRh+vunitv-vcorrect-answersv-Correctvanswer:vAnswerv1.
1.vO-
vnegativevbloodvisvconsideredvthevuniversalvdonorvbecausevitvdoesvnotvcontainvthevantigensvA,vB,vo
rvRh.v(AB+
isvconsideredvthevuniversalvrecipientvbecausevavpersonvwithvthisvbloodvtypevhasvallvthevanti-
gensvonvthevblood).
, 2.A+vbloodvcontainsvthevantigenvAvthatvthevclientvwillvreactvto,vcausingvthevdevelopmentvofvantibo
dies.vThevunitvbeingvRh+
isvcompatiblevwithvthevclient.
3.B+vbloodvcontainsvthevantigenvBvthatvthevclientvwillvreactvto,vcausingvthevdevelopmentvofvanti-
bodies.vThevunitvbeingvRh+
isvcompatiblevwithvthevclient.
4.ThisvclientvdoesvnotvhavevantigensvAvorvBvonvthevblood.vAdministrationvofvthesevtypesvwouldvcau
sevanvantigen/antibodyvreactionvwithinvthevclient'svbody,vresultingvinvavmassivevhemolysisvofvthevcl
ient'svbloodvandvdeath."
AboutvtenvminutesvaftervthevnursevbeginsvanvinfusionvofvpackedvRBCs,vthevpatientvcomplainsvofvchi
lls,vchestvandvbackvpain,vandvnausea.vHisvfacevisvflushed,vandvhe'svanxious.vWhichvisvthevpriorityvnu
rsingvaction?v
1.vAdministeringvantihistaminesvSTATvforvanvallergicvreaction.v
2.vNotifyingvthevphysicianvofvavpossiblevtransfusionvreaction.v
3.vObtainingvavurinevandvserumvspecimenvtovsendvtovthevlabvimmediately.v
4.vStoppingvhtevtransfusionvandvmaintainingvavpatentvIVvcatheter.v-vcorrect-answersv-
Thevcorrectvanswervisv4.vThevpatientvisvexperiencingvavtransfusionvreaction.vThevimmediatevnursin
gvactionvisvtovstopvthevtransfusionvandvmaintainvavpatentvIVvline.vThevothervoptionsvmayvbevindicat
edvbutvaren'tvthevpriorityvinvthisvcase.
Thevnursevisvadministeringvpackedvredvbloodvcellsv(PRBCs)vtovavclient.vThevnursevshouldvfirst:v
1.vDiscontinuevthevI.V.vcathetervifvavbloodvtransfusionvreactionvoccurs.
2.vAdministervthevPRBCsvthroughvavpercutaneouslyvinsertedvcentralv
cathetervlinevwithvav20-gaugevneedle.v
3.vFlushvPRBCsvwithv5%vdextrosevandv0.45%vnormalvsalinevsolution.v
4.vStayvwithvthevclientvduringvthevfirstv15vminutesvofvinfusion.v-vcorrect-answersv-Correct:v4
answers 2025
Thevnursevhasvobtainedvavunitvofvbloodvfromvthevbloodvbankvandvhasvcheckedvthevbloodvbagvprope
rlyvwithvanothervnurse.vJustvbeforevthevbeginningvtransfusion,vthevnursevassessesvwhichvofvthevfoll
owingvitems?
A.vVitalvsignsv
B.vSkinvColorv
C.vUrinevouputv
D.vLatestvhematocritvlevel.v-vcorrect-answersv-CorrectvAnswervAv
Changevinvvitalvsignsvduringvthevtransfusionvfromvthevbaselinevmayvindicatevthatvavtransfusionvrea
v
ctionvisvoccuring.vThisvisvwhyvnursevassessesvvitalvsignsvbeforevthevprocedurevandvagainvafterv15vmi
ntues.vThevothervoptionsvdovnotvidentifyvassessmentvthatvarevrequiredvjustvbeforevbeginningvavtra
nsfusion.
Thevphysicianvordersv2vunitsvofvpackedvRBCsvtovbevadministeredvtovthevclient.vAtv0600vthevnightvshi
ftvnursevinitiatesvthevfirstvunit'svtransfusionvbeforevgoingvoffvshift.vAtv1000vthevdayvshiftvnursevnote
svthevIVvlinevhasvclottedvoffvandvthevtransfusionvhasvnotvbeenvcompleted.vThevnursingvassessmentvr
evealedvthevtransfusionvwasvonlyvapproximatelyv75%vcomplete.vWhichvofvthevactionsvbyvthevnurse
visvmostvappropriate?
,A.vAdvisevthevbloodvbankvaboutvthevdelayvforvthevnextvunit.
B.vRestartvanothervperipheralvlinevwithv0.9%vNSvandvrestart
thevbloodvtransfusionvwithvthevremainingvbloodvunit.
C.vDiscontinuevthevtransfusion.
D.vDocumentvthevamountvinfusedvthusvfarvandvcontinuevthevtransfusion.v-vcorrect-answersv-
AnswervC
Rationale:vAvunitvofvbloodvshouldvbevadministered
v withinvav4vhourvperiodvofvtime.vThevnursevshouldvdiscontinuevthev
transfusion,vdocumentvthevfindingsvandvnotifyvthevbloodvbank.vThev
agencyvpolicyvwillvneedvtovbevfollowedvconcerningvthevdocumentationv
processvandvnotificationvofvappropriatevpersonnel.vContinuingvthev
transfusionvwithvthev"open"vunitvwillvexposevthevclientvtovanvincreasev
riskvofvinjury.
ThevclientvwithvO+vbloodvisvinvneedvofvanvemergencyvtransfusionvbutvthevlabvdoesvnotvhavevanyvO+v
bloodvavailable.vWhichvpotentialvunitvofvbloodvcouldvbevgivenvtovthevclient?
1.v0-vunit
2.vA+vunit
3.vB+vunit
4.vAnyvRh+vunitv-vcorrect-answersv-Correctvanswer:vAnswerv1.
1.vO-
vnegativevbloodvisvconsideredvthevuniversalvdonorvbecausevitvdoesvnotvcontainvthevantigensvA,vB,vo
rvRh.v(AB+
isvconsideredvthevuniversalvrecipientvbecausevavpersonvwithvthisvbloodvtypevhasvallvthevanti-
gensvonvthevblood).
, 2.A+vbloodvcontainsvthevantigenvAvthatvthevclientvwillvreactvto,vcausingvthevdevelopmentvofvantibo
dies.vThevunitvbeingvRh+
isvcompatiblevwithvthevclient.
3.B+vbloodvcontainsvthevantigenvBvthatvthevclientvwillvreactvto,vcausingvthevdevelopmentvofvanti-
bodies.vThevunitvbeingvRh+
isvcompatiblevwithvthevclient.
4.ThisvclientvdoesvnotvhavevantigensvAvorvBvonvthevblood.vAdministrationvofvthesevtypesvwouldvcau
sevanvantigen/antibodyvreactionvwithinvthevclient'svbody,vresultingvinvavmassivevhemolysisvofvthevcl
ient'svbloodvandvdeath."
AboutvtenvminutesvaftervthevnursevbeginsvanvinfusionvofvpackedvRBCs,vthevpatientvcomplainsvofvchi
lls,vchestvandvbackvpain,vandvnausea.vHisvfacevisvflushed,vandvhe'svanxious.vWhichvisvthevpriorityvnu
rsingvaction?v
1.vAdministeringvantihistaminesvSTATvforvanvallergicvreaction.v
2.vNotifyingvthevphysicianvofvavpossiblevtransfusionvreaction.v
3.vObtainingvavurinevandvserumvspecimenvtovsendvtovthevlabvimmediately.v
4.vStoppingvhtevtransfusionvandvmaintainingvavpatentvIVvcatheter.v-vcorrect-answersv-
Thevcorrectvanswervisv4.vThevpatientvisvexperiencingvavtransfusionvreaction.vThevimmediatevnursin
gvactionvisvtovstopvthevtransfusionvandvmaintainvavpatentvIVvline.vThevothervoptionsvmayvbevindicat
edvbutvaren'tvthevpriorityvinvthisvcase.
Thevnursevisvadministeringvpackedvredvbloodvcellsv(PRBCs)vtovavclient.vThevnursevshouldvfirst:v
1.vDiscontinuevthevI.V.vcathetervifvavbloodvtransfusionvreactionvoccurs.
2.vAdministervthevPRBCsvthroughvavpercutaneouslyvinsertedvcentralv
cathetervlinevwithvav20-gaugevneedle.v
3.vFlushvPRBCsvwithv5%vdextrosevandv0.45%vnormalvsalinevsolution.v
4.vStayvwithvthevclientvduringvthevfirstv15vminutesvofvinfusion.v-vcorrect-answersv-Correct:v4
