Blood Transfusion Administration Flashcards
Packed red blood cells have been prescribed for a female client with a hemoglobin level of 7.6 g/dL (76 mmol/L) and a hematocrit level of 30% (0.30). The nurse takes the client’s temperature before hanging the blood transfusion and records 100.6°F (38.1°C) orally. Which action should the nurse take?
If the client has a temperature higher than 100°F (37.8°C), 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, or may instruct the nurse to administer prescribed acetaminophen and wait until the temperature has decreased before administration, 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?
“Have you ever had a transfusion before?” Asking the client about personal experience with transfusion therapy provides a good starting point for client teaching about this procedure.
A client receiving a transfusion of packed red blood cells (PRBCs) begins to vomit. The client’s blood pressure is 90/50 mm Hg from a baseline of 125/78 mm Hg. The client’s temperature is 100.8°F (38.2°C) orally from a baseline of 99.2°F (37.3°C) orally. The nurse determines that the client may be experiencing which complication of a blood transfusion?
Septicemia occurs with the transfusion of blood contaminated with microorganisms. Signs include chills, fever, vomiting, diarrhea, hypotension, and the development of shock.
Signs of circulatory overload
dyspnea, cough, chest pain
The nurse determines that a client is having a transfusion reaction. After the nurse stops the transfusion, which action should be taken next?
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 reaction, is suspected. Normal saline is the solution of choice over solutions containing dextrose because saline does not cause red blood cells to clump.
tubing used for blood administration has _____________
an in-line filter. The filter helps to ensure that any particles larger than the size of the filter are caught in the filter and are not infused into the client.
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?
Vital signs 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 and thereafter per agency policy.
The nurse has just received a prescription to transfuse a unit of packed red blood cells for an assigned client. What action should the nurse take next?
Rationale: After receiving a prescription for a blood transfusion, the first action the nurse should take should be to check to be sure that consent for the transfusion has been signed by the client. If the client has consented, the nurse should then check a set of vital signs to be sure there is no contraindication for a transfusion at that time, such as an elevation in temperature. If the vital signs are acceptable, the nurse can then gather supplies to administer the transfusion and order the blood from the blood bank.
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?
New onset of tachycardia, bounding pulses, and crackles and wheezes posttransfusion is 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 IV 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?
The client who has neutropenia may receive a transfusion of granulocytes, or WBCs. These clients often have severe infections and are unresponsive to antibiotic therapy. The nurse notes the results of follow-up WBC 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.
_______________are a blood product used to replace erythrocytes.
Packed red blood cells
__________________is often used for volume expansion as a result of fluid and blood loss. It is rich in clotting factors and can be thawed quickly and transfused quickly.
Fresh-frozen plasma
_______________are used to treat thrombocytopenia and platelet dysfunction.
Platelets
Regarding blood administration, __________________ may be used to treat a client with sepsis or a neutropenic client with an infection that is unresponsive to antibiotics.
Granulocytes may be used to treat a client with sepsis or a neutropenic client with an infection that is unresponsive to antibiotics.
What is an autologous blood donation ?
person gives their own blood. This reduces risks of disease transmission and transfusion complications.
The next most effective way is to ask a family member to donate blood before surgery.
A donation of the client’s own blood before a scheduled procedure is autologous. Donating autologous blood to be reinfused as needed during or after surgery reduces the risk of disease transmission and potential transfusion complications.
