Blood Transfusion NCLEX Questions and Answers

Blood Transfusion NCLEX Questions and Answers

"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

• A+ unit
• B+ unit

4. Any Rh+ unit" - answer"Correct answer: Answer 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."

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. - answer3) 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.

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?

• Administering antihistamines STAT for an allergic reaction.
• Notifying the physician of a possible transfusion reaction.
• Obtaining a urine and serum specimen to send to the lab immediately.
• Stopping hte transfusion and maintaining a patent IV catheter." - answerThe correct answer is
• 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 has discontinued a unit of blood that was infusing into a client because the client experienced a transfusion reaction. After documenting the incident appropriately, the nurse sends the blood bag and tubing to which of the following departments?

• Blood bank
• Risk management

• Environmental services
• Infection control - answerA. blood bank

The nurse returns the blood transfusion bag containing any remaining blood to the blood bank.This allows the blood bank to complete any follow-up testing procedures needed once a transfusion reaction has been documented. The other option identify incorrect departments.

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?" - answer1) "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.

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 - answerCorrect: 3?? 4

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.

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 - answer1) 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.