Blood Transfusions

Question 1

ANS: C
People with type AB blood have neither antibody and therefore can receive all blood types.
A patient with a history of iron-deficiency anemia who has not taken iron supplements for several years is experiencing increased fatigue and dizziness. What would the nurse expect the patient’s laboratory findings to include?
a. Hematocrit 0.38 (38%)
b. Red blood cell (RBC) count 4,500,000/µL
c. Hemoglobin (Hb) 86 g/L
d. Normal RBC indices

Answer 1

ANS: C

The patient’s clinical manifestations indicate moderate anemia, which is consistent with an Hb of 60 to 100 g/L.

Question 2

When the nurse discusses foods high in iron with a patient who has iron-deficiency anemia, the patient tells the nurse that she prepares low-cholesterol foods for her family and probably does not eat enough meat to meet her iron requirements. It is an appropriate goal for the patient to increase dietary intake of which of the following?

a. Eggs and fish
b. Nuts and cornmeal
c. Milk and milk products
d. Legumes and dried fruit

Answer 2

ANS: D

Legumes and dried fruits are high in iron and low in fat and cholesterol

Question 3

Which one of the following groups of people is at an increased risk for developing iron-deficiency anemia?

a. Postmenopausal women
b. Middle-class people
c. Pregnant women
d. School-aged males

Answer 3

ANS: C
Those at risk for the development of iron-deficiency anemia are premenopausal and pregnant women, people from low socioeconomic backgrounds, older adults, and individuals experiencing blood loss.

Question 4

A 52-year-old patient has pernicious anemia with long-standing weakness and paraesthesia of the feet and hands. The nurse determines that expected outcomes related to knowledge of the therapeutic regimen have been met when the patient states which of the following?

a. “I will need to have cobalamin (B12) injections regularly for the rest of my life.”
b. “I will increase sources of cobalamin (B12), such as muscle meats and liver, in my diet.”
c. “The feeling in my hands and feet will return when my hemoglobin level returns to normal.”
d. “I should plan for only part-time employment because of the chronic fatigue that pernicious anemia causes.”

Answer 4

ANS: A
Pernicious anemia prevents the absorption of vitamin B12, and the patient requires injections or intranasal administration of cobalamin.

Question 5

A patient with chronic lymphocytic leukemia is hospitalized for treatment of severe hemolytic anemia. What is an appropriate nursing intervention for the patient?

a. Provide a diet high in vitamin K and folic acid.
b. Plan care to alternate periods of rest and activity.
c. Isolate the patient from visitors and other patients.
d. Encourage increased intake of fluid and fibre in the diet.

Answer 5

ANS: B
Nursing care for patients with anemia should alternate periods of rest and activity to maintain patient mobility without causing undue fatigue.

Question 6

After teaching the patient about taking oral iron preparations for a moderate iron-deficiency anemia, which of the following patient statements indicates to the nurse that additional instruction is needed?

a. “I will contact my doctor if my stools start to turn black.”
b. “I will call the doctor if the tablets cause a lot of stomach upset.”
c. “I will increase my fluid intake if the iron tablets make me constipated.”
d. “I should take the iron tablets with orange juice about an hour before meals.”

Answer 6

ANS: A
It is normal for the stools to appear black when a patient is taking iron, and the patient should not call the doctor about this.

Question 7

A 42-year-old patient is admitted to the hospital with idiopathic aplastic anemia. What is an appropriate collaborative problem for the nurse to identify for the patient?

a. Potential complication: seizures
b. Potential complication: hemorrhage
c. Potential complication: neurogenic shock
d. Potential complication: pulmonary edema

Answer 7

ANS: B

Because the patient with aplastic anemia has pancytopenia, the patient is at risk for bleeding and infection

Question 8

A patient with sickle cell anemia is admitted to the hospital in crisis with severe abdominal pain. While caring for the patient, what is it most important for the nurse to do?

a. Limit the patient’s intake of oral fluids.
b. Evaluate the effectiveness of narcotic analgesics.
c. Encourage the patient to ambulate as much as tolerated.
d. Teach the patient about high-protein, high-calorie foods.

Answer 8

ANS: B
Pain is the most common clinical manifestation of a crisis and usually requires large doses of continuous opioids for control.

Question 9

A 21-year-old patient is having a sickle cell crisis for the first time in many years. He asks the nurse why the sickling causes such pain. The nurse should explain that the pain of sickling is caused by which of the following?

a. Spasms of the blood cells as they change shape
b. Deposition of sickled red cells in the bone marrow
c. Tissue hypoxia caused by small blood vessel occlusion
d. Bacterial or viral infections of organs that caused the sickling

Answer 9

ANS: C
The pain associated with a sickle cell crisis is caused by ischemia, as the sickled cells occlude small blood vessels and capillaries.

Question 10

During discharge teaching for the patient with neutropenia, which of the following issues should the nurse include?

a. Caffeine and alcohol intake
b. Excessive dietary iron intake
c. Limiting fluids to 2 L per day
d. Exposure to crowds

Answer 10

ANS: D
Patients with neutropenia should be instructed to avoid crowds and people who have colds, flu, or infections. If they are in a public area, they should be taught to wear a mask.

Question 11

A patient who has experienced an acute blood loss exhibits a normal supine blood pressure and pulse at rest but complains of postural hypotension and has a pulse of 110 beats/min when exercising. The nurse knows that these signs and symptoms are manifestations of what percentage of blood loss?

a. 10%
b. 20%
c. 30%
d. 40%

Answer 11

ANS: C
A patient who has experienced an acute blood loss and exhibits a normal supine blood pressure and pulse at rest but complains of postural hypotension and has a pulse of 110 beats/min when exercising has lost approximately 30% of their total blood volume.

Question 12

During the admission assessment of a patient who has an Hb of 4.7 mmol/L (7.6 g/dL) and jaundice of the sclera, what laboratory results would the nurse assess?

a. Stool occult blood
b. Bilirubin level
c. Schilling test
d. Gastric analysis testing

Answer 12

ANS: B
Jaundice is caused by the elevation of bilirubin level associated with RBC hemolysis. The presence of jaundice suggests a hemolytic anemia, rather than gastrointestinal bleeding or cobalamin deficiency, as the cause of the anemia.

Question 13

The physician orders transfusion with packed RBCs for a patient who has severe anemia resulting from a bleeding peptic ulcer. What is the most important nursing action to prevent a transfusion reaction when administering the blood?

a. Verify and document patient identification.
b. Keep the blood chilled during administration.
c. Administer the blood at a rate of no more than 2 mL/min.
d. Stay with the patient during the first 15 minutes of the transfusion.

Answer 13

ANS: A

Improper identification is responsible for 90% of hemolytic transfusion reactions.

Question 14

A patient receiving a transfusion of whole blood develops chills and fever, headache, and anxiety 30 minutes after the transfusion is started. Which of the following does the nurse implement after stopping the transfusion?

a. Send a urine specimen to the laboratory.
b. Administer acetaminophen (Tylenol).
c. Give diphenhydramine (Benadryl).
d. Draw blood for a new crossmatch.

Answer 14

ANS: B
The patient’s clinical manifestations are consistent with a febrile, nonhemolytic transfusion reaction. The transfusion should be stopped and antipyretics administered for the fever as ordered

Question 15

Fifteen minutes after a transfusion of packed RBCs is started, a patient develops tachycardia and tachypnea, and complains of back pain and feeling warm. What is the nurse’s priority action?

a. Discontinue transfusion, and infuse normal saline.
b. Administer oxygen therapy at a high flow rate.
c. Slow the transfusion rate, and reassess the patient in 15 minutes.
d. Stop the blood, and discard the used bag and tubing in a biohazard container.

Answer 15

ANS: A
The first action should be to disconnect the transfusion and infuse normal saline to keep the line open and maintain the patient’s blood pressure. The other actions are also needed but are not the highest priority

Question 16

A patient who has been receiving a heparin infusion and warfarin (Coumadin) for a deep-vein thrombosis is diagnosed with heparin-induced thrombocytopenia and thrombosis syndrome (HITTS). What does the nurse anticipate that the physician will order?

a. Use saline for flushing intravenous (IV) lines.
b. Give low–molecular weight (LMW) heparin.
c. Discontinue the warfarin.
d. Administer platelet transfusions.

Answer 16

ANS: A
All heparin is discontinued when the HITTS is diagnosed. The patient should be instructed never to receive heparin or LMW heparin; therefore, saline will be ordered for flushing IV lines

Question 17

During treatment of the patient with an acute exacerbation of polycythemia vera, what is a critical nursing intervention?

a. Administer oxygen.
b. Evaluate fluid balance.
c. Administer anticoagulants.
d. Administer parenteral iron.

Answer 17

ANS: B
Monitoring hydration status is important during an acute exacerbation because the patient is at risk for fluid overload or underhydration.

Question 18

For which one of the following lab results would the nurse expect to see abnormal results in a patient who has hemophilia?

a. Thrombin time
b. Platelet count
c. Prothrombin time
d. Partial thromboplastin time

Answer 18

ANS: D
Partial thromboplastin time is prolonged in patients with hemophilia because of a deficiency in any intrinsic clotting system factor. Prothrombin time, thrombin time, and platelet count are expected to be normal in a patient with hemophilia

Question 19

Of the following patients waiting to be admitted by the emergency department nurse, which one requires the most rapid assessment and care by the nurse?

a. The patient with a history of sickle cell anemia who has had nausea and diarrhea for 24 hours
b. The patient who has chemotherapy-induced neutropenia and a temperature of 38°C
c. The patient with thrombocytopenia who has oozing after having a tooth extracted
d. The patient with hemophilia A who has ankle swelling after twisting the ankle

Answer 19

ANS: B
A neutropenic patient with a fever is assumed to have an infection and is at risk for rapidly developing sepsis. Rapid assessment, cultures, and initiation of antibiotic therapy are needed.

Question 20

While a patient with severe acquired thrombocytopenia is receiving platelet transfusions, the nurse recognizes that a platelet transfusion reaction may be present when the patient experiences which of the following signs?

a. Flushing, itching, and urticaria
b. Sudden onset of chills and fever
c. Urticaria, wheezing, and hypotension
d. Tachycardia, tachypnea, and hemoglobinuria

Answer 20

ANS: B

Sudden onset of both chills and fever indicates a transfusion reaction.

Question 21

The nurse identifies a nursing diagnosis of risk for injury related to medical interventions for a patient with immune thrombocytopenic purpura. What is an appropriate nursing intervention that addresses the etiology of this nursing diagnosis?

a. Use a soft-bristled toothbrush and cotton swabs for mouth care.
b. Limit the number of venipunctures by using an intermittent-infusion device.
c. Assess the patient during the platelet transfusion for symptoms of transfusion reactions.
d. Assess the patient’s mucous membranes and skin each shift to detect the presence of bleeding.

Answer 21

ANS: B
Limit the number of venipunctures; intramuscular or subcutaneous injections should be avoided because of the risk for bleeding.

Question 22

When preparing a patient for a blood transfusion, the nurse will prepare the blood. Which IV solution would the nurse prepare to administer in a Y-type tubing adjacent to the blood?

a. Dextrose 5%
b. Lactated Ringer’s
c. Normal saline
d. Dextrose 10%

Answer 22

ANS: C
When preparing a patient for a blood transfusion, the nurse will prepare the blood and attach normal saline to Y-type tubing adjacent to the blood for administration.

Question 23

A patient with type A hemophilia has been admitted to the hospital with severe pain and swelling in his right knee. To prevent joint deformity during the initial care of the patient, what should the nurse do?

a. Immobilize the knee.
b. Elevate the right lower limb on pillows.
c. Perform passive range of motion to the knee.
d. Have the patient perform isometric exercises of the affected leg against a footboard.

Answer 23

ANS: A

The initial action should be total rest of the knee to minimize bleeding.

Question 24

Laboratory studies related to coagulation are performed on a patient with a bleeding disorder. The nurse explains to the patient that von Willebrand’s disease can be differentiated from other types of hemophilia by evaluating which of the following laboratory results?

a. Bleeding time
b. Platelet count
c. Prothrombin time
d. Partial thromboplastin time

Answer 24

ANS: A
The bleeding time is affected by von Willebrand’s disease. Platelet count, prothrombin time, and partial thromboplastin time are normal in von Willebrand’s disease.

Question 25

When caring for a patient with hemophilia, the nurse teaches the patient to seek immediate medical attention on experiencing which of the following signs? a. Fever b. A sore throat c. Bleeding gums d. Dark, tarry stools (melena)

Answer 25

ANS: D | Melena is a sign of gastrointestinal bleeding and requires further assessment.

Question 26

A patient’s family member asks the nurse what caused the patient to develop disseminated intravascular coagulation (DIC). What does the nurse tell the family member about DIC? a. It is caused by an abnormal activation of clotting. b. It occurs when the immune system attacks platelets. c. It is a complication of cancer chemotherapy. d. It is caused when hemolytic processes destroy erythrocytes.

Answer 26

ANS: A | DIC is an abnormal response of the clotting cascade stimulated by a variety of diseases or disorders

Question 27

During treatment of the patient who has sepsis-induced DIC with moderate bleeding, on what would the nurse expect the initial collaborative care will focus? a. Administration of heparin to reduce intravascular clotting b. Treatment of the infectious process with IV antibiotics c. Infusion of whole blood to replace clotting factors and RBCs d. Supportive management of symptoms until the DIC is resolved

Answer 27

ANS: B Treatment of the acute sepsis is essential to resolving the DIC and will be the major focus of collaborative care. Heparin administration is controversial in DIC, although it may be used if the DIC does not resolve and clotting factors continue to decrease.

Question 28

A patient with myelodysplastic syndrome has laboratory values that indicate total bone marrow suppression. The nurse identifies a nursing diagnosis of risk for infection based on which of the following findings? a. Basophils 120 cells/mL b. Monocytes 360 cells/mL c. Neutrophils 4000 cells/mL d. White blood cell (WBC) count 2.8 × 109 cells/L (2800 cells/microlitre)

Answer 28

ANS: D The low WBC count indicates a risk for infection. The nurse should notify the physician and expect an order to check the differential WBC count.

Question 29

What is the most appropriate nursing intervention to assess for the presence of infection in a patient with neutropenia? a. Monitor WBCs daily. b. Monitor temperature every 4 hours. c. Monitor the skin for temperature and diaphoresis. d. Monitor the mouth and perianal area every shift for signs of redness and swelling.

Answer 29

ANS: B The earliest sign of infection in a neutropenic patient is an elevation in temperature. Patients with neutropenia (low neutrophil count) are susceptible to infection and may be febrile.

Question 30

A patient receiving chemotherapy for acute lymphocytic leukemia has pancytopenia, and filgrastim (Neupogen) is prescribed. The nurse teaches the patient that the reason for the use of the medication is which of the following? a. Remission of the leukemia b. Improvement in the number and function of neutrophils c. Replacement of abnormal stem cells in the bone marrow with normal cells d. Prevention of hemorrhage complications in patients with thrombocytopenia

Answer 30

ANS: B | Filgrastim increases the neutrophil count and function in neutropenic patients.

Question 31

A 64-year-old patient with newly diagnosed acute myelogenous leukemia (AML) is undergoing induction therapy with chemotherapeutic agents. He tells the nurse that he is so sick from the induction therapy that he wonders if it is worth it. What is the best response to this patient? a. “I know you feel really ill right now, but after this therapy, your disease will go into a remission, and you will feel normal again.” b. “Induction therapy is very aggressive and causes the most side effects, so when this phase is completed, you won’t feel so ill.” c. “Your type of leukemia has a survival rate of up to 10 years if aggressive therapy is started, so the effects of treatment should be worth it to you.” d. “I know that this phase is very difficult for you, but the treatment is necessary to achieve control of your disease so that you will have some time to make choices about your life.”

Answer 31

ANS: D | AML is very aggressive, and survival after diagnosis is short without treatment.

Question 32

A patient with chemotherapy-induced neutropenia is placed in a private room, and protective isolation is instituted. The care plan the nurse develops with the patient is based on the knowledge that which of the following sources of infection is the most common in patients with neutropenia? a. Normally nonpathogenic microorganisms of the patient’s own flora b. Microorganisms that are not sensitive to broad-spectrum antibiotics c. Microorganisms transmitted to the patient by the hands of health care providers d. Microorganisms transmitted to the patient by health care providers with transmissible infections

Answer 32

ANS: A An important consideration in the care of a neutropenic patient is the determination of the best means to protect the patient whose own defences against infection are compromised. To accomplish this goal, the following principles must be kept in mind: (1) the patient’s normal flora are the most common source of microbial colonization and infection; (2) transmission of organisms from humans most commonly occurs by direct contact with the hands; (3) air, food, water, and equipment provide additional opportunities for infection transmission; and (4) health care providers with transmissible illnesses and other patients with infections can also be sources of infection transmission under certain conditions.

Question 33

A patient with neutropenia has a nursing diagnosis of risk for infection. What is the most important nursing intervention in the prevention of transmission of harmful pathogens to the patient? a. Prohibiting the oral intake of fresh fruits and vegetables b. Maintaining strict administration schedules of prophylactic antibiotics c. Strict and frequent handwashing by all persons having contact with the patient d. Creating a “sterile” environment for the patient with the use of laminar airflow rooms

Answer 33

ANS: C | Infection control measures such as handwashing are necessary for the patient with neutropenia

Question 34

A 45-year-old woman with chronic myelogenous leukemia is considering the possibility of treatment with a bone marrow transplant from a human leukocyte antigen–matched sibling. To assist the patient with treatment decisions, what is the best approach for the nurse to use? a. Emphasize the positive outcomes of a bone marrow transplant. b. Ensure that the patient understands the risks of treatment-related death or treatment failure. c. Explain that a cure is not possible with any other type of treatment except a bone marrow transplant. d. Encourage the patient to ask the physician about new, experimental treatments for leukemia that do not involve total body irradiation.

Answer 34

ANS: B Offering the patient an opportunity to ask questions or discuss concerns about hematopoietic stem cell transplantation will encourage the patient to voice concerns about this treatment and will also allow the nurse to assess whether the patient needs more information about the procedure

Question 35

During care of the patient with multiple myeloma, what is an important nursing intervention? a. Limiting activity to prevent pathological fractures b. Maintaining a fluid intake of 3 to 4 L/day to dilute calcium load c. Assessing for changes in size and characteristics of lymph nodes d. Administering narcotic analgesics continuously to control bone pain

Answer 35

ANS: B A high fluid intake and urinary output help prevent the complications of kidney stones arising from hypercalcemia and renal failure caused by deposition of Bence-Jones protein in the renal tubules.

Question 36

A patient with non-Hodgkin’s lymphoma develops a platelet count of 10,000 cells/microlitre during chemotherapy. Based on this finding, what is an appropriate nursing intervention for the patient? a. Provide oral hygiene every 2 hours. b. Check the temperature every 4 hours. c. Check all stools for occult blood. d. Encourage fluids to 3000 mL/day.

Answer 36

ANS: C | Because the patient is at risk for spontaneous bleeding, the nurse should check stools for occult blood.

Question 37

A 26-year-old patient with stage II Hodgkin’s disease asks the nurse how long he probably has to live. What is the best response to the patient? a. “No one can predict when someone will die, so try to focus on the present.” b. “It will depend on how your disease responds to chemotherapy, but most patients do well.” c. “If your initiation chemotherapy is effective, it is possible to have at least a 5-year remission.” d. “Most patients with your stage of Hodgkin’s disease are treated successfully.”

Answer 37

ANS: D | The survival rate is almost 90% in patients with the early stages of Hodgkin’s lymphoma.

Question 38

Which nutrient plays a role in helping mature RBCs in erythropoiesis? a. Iron b. Folic acid c. Pyridoxine d. Ascorbic acid

Answer 38

ANS: B | Folic acid’s role in erythropoiesis is to cause RBC maturation.

Question 39

While monitoring a patient’s cardiac activity, the nurse recognizes that stimulation of which of the following is a normal physiological mechanism responsible for an increase in heart rate (HR) and force of cardiac contractions? a. The vagus nerve b. Baroreceptors in the aortic arch and carotid sinus c. α-Adrenergic receptors in the vascular system d. Chemoreceptors in the aortic arch and carotid body

Answer 39

ANS: D Chemoreceptors located in the aortic arch and carotid body are capable of initiating changes in HR and arterial pressure in response to decreased arterial O2 pressure, increased arterial carbon dioxide pressure, and decreased plasma pH.

Question 40

While assessing a patient who has just arrived in the emergency department, the nurse notes a pulse deficit. Which of the following does the nurse anticipate that the patient may require? a. Hourly blood pressure (BP) checks b. A coronary arteriogram c. Electrocardiographic (ECG) monitoring d. A two-dimensional echocardiogram

Answer 40

ANS: C Pulse deficit is a difference between simultaneously obtained apical and radial pulses and indicates that dysrhythmias might be detected with ECG monitoring

Question 41

A patient has a BP of 142/84 mm Hg. The nurse will calculate and document the patient’s mean arterial pressure (MAP) as being which following amount? a. 103 mm Hg b. 113 mm Hg c. 123 mm Hg d. 131 mm Hg

Answer 41

ANS: A | MAP = Diastolic BP + 1/3 Pulse pressure.

Question 42

The nurse is monitoring a patient with possible coronary artery disease who is undergoing exercise (stress) testing on a treadmill. Which symptom has the most immediate implications for the patient’s care during the exercise testing? a. BP rising from 134/68 to 150/80 mm Hg b. HR increasing from 80 to 96 beats/min c. Patient complaining of feeling short of breath d. ECG indicating the presence of coronary ischemia

Answer 42

ANS: D ECG changes associated with coronary ischemia (such as T-wave inversions and ST-segment depression) indicate that the myocardium is not getting adequate oxygen delivery and that the exercise test should be terminated immediately

Question 43

During physical examination of a 56-year-old man, the nurse palpates the point of maximal impulse (PMI) in the sixth intercostal space lateral to the midclavicular line. What is the most appropriate interpretation of this finding? a. The PMI is in the normal location. b. The patient may have left ventricular hypertrophy. c. The patient has age-related downward displacement of the heart. d. The patient should be observed for signs of left atrial enlargement.

Answer 43

ANS: B The PMI should be felt at the intersection of the fifth intercostal space and the midclavicular line. A PMI located outside these landmarks indicates possible cardiac enlargement, such as with left ventricular hypertrophy.

Question 44

To auscultate for extra heart sounds in the mitral area, with what part of the stethoscope will the nurse listen? a. The bell of the stethoscope with the patient in the left lateral position b. The diaphragm of the stethoscope with the patient in a reclining position c. The diaphragm of the stethoscope with the patient lying flat on the left side d. The bell of the stethoscope with the patient sitting and leaning to the right side

Answer 44

ANS: A Gallop rhythms generate low-pitched sounds and are most easily heard with the bell of the stethoscope. Sounds associated with the mitral valve are accentuated by turning the patient to the left side, which brings the heart closer to the chest wall.

Question 45

The standard orders on the cardiac unit state, “Notify the physician for MAP less than 70 mm Hg.” For which patient would the nurse call the physician? a. The patient with left ventricular failure who has a BP of 110/70 mm Hg b. The patient with a myocardial infarction who has a BP of 114/50 mm Hg c. The postoperative patient with a BP of 116/42 mm Hg d. The newly admitted patient with a BP of 122/60 mm Hg

Answer 45

ANS: C The MAP is calculated using the formula MAP = (Diastolic BP + 1/3 Pulse Pressure). The MAP for the postoperative patient in C is 67 mm Hg. The MAP in the other three patients is higher than 70 mm Hg.

Question 46

During physical examination of a 72-year-old patient, the nurse observes pulsation of the abdominal aorta in the epigastric area just below the xiphoid process. How will the nurse interpret this finding? a. Normal assessment data in a thin person b. Sclerosis and inelasticity of the aorta c. A possible abdominal aortic aneurysm d. Evidence of elevated systemic arterial pressure

Answer 46

ANS: A | Visible pulsation of the abdominal aorta is commonly observed in the epigastric area for thin individuals.

Question 47

A patient is scheduled for cardiac catheterization with coronary angiography. Before the test, about which of the following should the nurse inform the patient? a. A catheter will be inserted into a vein in the arm or leg and advanced to the heart. b. ECG monitoring will be required for 24 hours following the test to detect any dysrhythmias. c. A feeling of warmth and a fluttering sensation may be experienced as the catheter is advanced. d. Complications of the test include breaking of the catheter, air or blood embolism, and puncture of the ventricles.

Answer 47

ANS: C A sensation of warmth or flushing is common when the iodine-based contrast material is injected, which can produce anxiety unless it has been discussed with the patient.

Question 48

Which of the following is a normal cardiac index (CI) assessment finding? a. 2 L/min b. 3 L/min/m2 c. 6 L/min d. 8 L/min/m2

Answer 48

ANS: B | The normal range for a CI reading is 2.8 to 4.2 L/min/m2.

Question 49

What should the nurse teach the patient being evaluated for rhythm disturbances with a Holter monitor to do? a. Remove the electrodes to shower or bathe. b. Exercise as much as possible while his monitor is in place. c. Keep a diary of his activities as long as he wears the monitor. d. Attach the recorder, and call the assigned number if an episode of irregular heartbeats occurs.

Answer 49

ANS: C The patient is instructed to keep a diary describing daily activities while Holter monitoring is being accomplished to help correlate any rhythm disturbances with patient activities.

Question 50

When auscultating over the patient’s abdominal aorta, the nurse hears a humming sound. How will the nurse document this finding? a. Bruit b. Thrill c. Heave d. Arterial obstruction

Answer 50

ANS: A | A bruit is the sound created by turbulent blood flow in an artery.

Question 51

The physician orders serum troponin levels in a patient with a possible myocardial infarction. What will the nurse explain to the patient about this test? a. It is the most specific indicator for myocardial damage available. b. It measures the amount of myoglobin released from damaged myocardial cells. c. It can provide evidence of myocardial damage more quickly than can enzyme tests. d. It is diagnostic for myocardial damage only when used in combination with creatinine kinase-MB isoenzymes.

Answer 51

ANS: C | Cardiac troponins start to elevate 1 hour after myocardial injury and are specific to myocardium.

Question 52

Which of the following is a normal age-related change in the heart? a. Increased elastin b. Decreased collagen c. Decreased cardiac output d. Increased stroke volume

Answer 52

ANS: C A normal age-related change in the heart is a decrease in cardiac output. Elastin and stroke volume are decreased, and collagen is increased.

Question 53

The nurse hears a murmur between the S1 and S2 heart sounds at the patient’s left fifth intercostal space and midclavicular line. What is the best way to record this information? a. “Systolic murmur heard at mitral area.” b. “Diastolic murmur heard at aortic area.” c. “Systolic murmur heard at Erb’s point.” d. “Diastolic murmur heard at tricuspid area.”

Answer 53

ANS: A The S1 sound is created by closure of the mitral and tricuspid valves and signifies the onset of ventricular systole. S2 is caused by the closure of the aortic and pulmonic valves and signifies the onset of diastole. A murmur occurring between these two sounds is a systolic murmur.

Question 54

What should the nurse expect as a possible etiology in a patient who exhibits a positive Homans sign? a. Thyrotoxicosis b. Thrombophlebitis c. Incompetent valves d. Intermittent claudication

Answer 54

ANS: B | The nurse should suspect thrombophlebitis in a patient who exhibits a positive Homans sign.

Question 55

Upon auscultation, the nurse identifies an arterial bruit. What is a possible cause? a. Cardiac dysrhythmias b. Aneurysm c. Pericarditis d. Cardiac valve disorder

Answer 55

ANS: B | An arterial bruit is suggestive of wither an aneurysm or an arterial obstruction.

Question 56

The registered nurse (RN) is observing a student nurse who is doing a physical assessment on a patient. The RN will need to intervene immediately if the student does which of the following? a. Presses on the skin over the tibia for 10 seconds to check for edema b. Palpates both carotid arteries simultaneously to compare pulse quality c. Places the patient in the left lateral position to check for the PMI d. Uses the palm of the hand to assess extremity skin temperature

Answer 56

ANS: B The carotid pulses should never be palpated at the same time to avoid vagal stimulation, dysrhythmias, and decreased cerebral blood flow. The other assessment techniques also need to be corrected; however, they are not dangerous to the patient.

Question 57

A patient with syncope is scheduled for Holter monitoring. When teaching the patient about the purpose of the procedure, the nurse explains that Holter monitoring provides information about which of the following? a. Ventricular ejection fraction during usual daily activities b. Cardiovascular response to high-intensity exercise c. Changes in cardiac output when the patient is resting d. HR and rhythm during normal patient activities

Answer 57

ANS: D Holter monitoring is used to assess for possible changes in HR or rhythm over a 24- to 48-hour period. The patient is usually instructed to continue with usual daily activities rather than changing exercise or activity level.

Question 58

A transesophageal echocardiogram (TEE) is ordered for a patient with possible endocarditis. Which of these actions included in the standard TEE orders will the nurse need to accomplish first? a. Make the patient nothing by mouth (NPO) status. b. Start a large-gauge IV line. c. Administer O2 per mask. d. Give lorazepam (Ativan) 1 mg IV.

Answer 58

ANS: A The patient will need to be NPO status for 6 hours preceding the TEE, so the nurse should place the patient on NPO status as soon as the order is received.

Question 59

Which one of the following central venous pressure (CVP) readings would the nurse report to the physician as being abnormal? a. 3 mm Hg b. 6 mm Hg c. 9 mm Hg d. 12 mm Hg

Answer 59

ANS: D | The normal CVP reading is 2 to 9 mm Hg.

Question 60

For how long may blood preserved with CPD be stored (unfrozen) before use? a. 21 days b. 35 days c. 42 days d. 3 months

Answer 60

ANS: A | When preserved with citrate, phosphate, and dextrose a unit of blood has a shelf life of 21 days (unfrozen).

Question 61

The nurse is caring for a patient who needs a blood transfusion. The patient has been tested and was found to have blood type O. The nurse knows this means that which antigen is present on the surface of the red blood cells? a. The type A antigen is present. b. The type B antigen is present. c. Neither type A nor type B antigens are present. d. Both type A and type B antigens are present.

Answer 61

ANS: C When neither A nor B antigens are present, the blood group is type O. When the type A antigen is present, the blood group is type A. When the type B antigen is present, the blood group is type B. When both A and B antigens are present, the blood group is type AB.

Question 62

A nurse is concerned about the type of blood that a patient is to receive. A patient with an O blood type may safely receive which type of blood? a. Type A blood b. Type B blood c. Type AB blood d. Type O blood

Answer 62

ANS: D People with type O blood have both A and B antibodies and therefore can receive only type O blood. People with type A blood have anti-B antibodies and therefore can receive only type A blood. People with type B blood have anti-A antibodies and therefore can receive only type B blood. People with type AB blood have neither antibody and therefore can receive all blood types.

Question 63

The patient is scheduled to receive a blood transfusion. Preadministration laboratory tests are run to assess the level of which component in the patient’s blood? a. Sodium (Na) b. Calcium (Ca) c. Potassium (K) d. Iron (Fe)

Answer 63

ANS: C When blood is stored, there is continual destruction of RBCs, which releases potassium from the cells into the plasma. If blood is transfused rapidly, transient elevated potassium levels may occur before the potassium is reabsorbed and put the patient at risk

Question 64

The patient has received a total of 7 units of blood over the past 8 hours. The nurse assesses the patient’s laboratory test results. Which of the following would be an expected complication? a. Hypokalemia b. Hyperkalemia c. Hypercalcemia d. Iron deficiency

Answer 64

ANS: B When blood is stored, there is continual destruction of RBCs, which releases potassium from the cells into the plasma. If blood is transfused rapidly, transient hyperkalemia may occur before the potassium is reabsorbed. Blood that is preserved with citrate phosphate dextrose (CPD) contains a high concentration of citrate ions. The excess citrate may combine with the ionized calcium in the recipient’s blood, resulting in transient low ionized calcium levels. Patients receiving multiple transfusions should be assessed for iron overload.

Question 65

The patient is to receive 2 units of packed RBCs. The units are cold, and the nurse is concerned that this could lead to dysrhythmias and/or a reduction in core temperature. What action may the nurse take to prevent this? a. Warm the blood in a microwave. b. Warm the blood using hot water. c. Warm the blood using a blood warmer. d. Allow the blood to warm to room temperature before administering.

Answer 65

ANS: C In emergency situations, rapid transfusion of cold blood may lead to dysrhythmias and a reduction in core temperature. Sometimes a blood warmer machine is used for large transfusions of greater than 50 mL/kg/hr or in patients with cold agglutinins. Heating blood products in a microwave or with hot water is dangerous and may destroy blood cells. Blood must be given within a prescribed time frame. Allowing the blood to come to room temperature before administration would decrease the time available for administration.

Question 66

The patient is scheduled to receive 1 unit of packed RBCs. She has small, fragile veins, and a 22-gauge intravenous (IV) patent catheter is in place. What should the nurse do? a. Cancel the blood transfusion. b. Insert a 16-gauge IV catheter into the antecubital fossa. c. Use the IV catheter that is in place. d. Transfuse the blood over 6 hours.

Answer 66

ANS: C In emergency situations that require rapid transfusions, a large-gauge cannula is preferred; however, transfusions for therapeutic indications may be infused with cannulas ranging from 20 to 24 gauge. Large-gauge cannulas (18 or 20 gauge) promote rapid flow of blood components. 16-Gauge catheters are used frequently in surgery, but not usually on acute care units. Blood must be transfused within 4 hours. Use of smaller-gauge cannulas, such as 24 gauge, often requires the blood bank to divide the unit so that each half can be infused within the allotted time or requires the use of pressure-assisted devices.

Question 67

What primary intervention should a nurse who is preparing a blood transfusion perform? a. Set up the Y tubing. b. Obtain 0.9% saline. c. Verify the blood product and the patient. d. Have the patient void or empty the urine drainage container.

Answer 67

ANS: C Correctly verify the product and identify the patient with a person considered qualified by your agency. Strict adherence to verification procedures before administration of blood or blood components reduces the risk of administering the wrong blood to the patient. Clerical errors are the cause of most hemolytic transfusion reactions. Y tubing is used to facilitate maintenance of IV access in case a patient will need more than 1 unit of blood. However, the focus here is on prevention of possible blood reactions. Use of Y tubing will not prevent a blood reaction. Normal saline is compatible with blood products, unlike solutions that contain dextrose, which causes coagulation of donor blood. However, strict adherence to verification procedures before administration of blood or blood components reduces the risk of administering the wrong blood to the patient. Empty the urine drainage collection container or have the patient void. If a transfusion reaction occurs, a urine specimen containing urine produced after initiation of the transfusion will be sent to the laboratory.

Question 68

The patient is to receive 1 unit of packed RBCs. The nurse obtains the blood from the blood bank and returns to the unit to find that the patient has been taken to radiology for a CT scan and is expected to return in about an hour. What should the nurse do? a. Go to radiology and administer the blood. b. Keep the blood refrigerated until the patient returns. c. Return the blood to the blood bank. d. Hang the blood in the patient’s room and start it when the patient returns.

Answer 68

ANS: C Initiate the blood transfusion within 30 minutes of the time of release from the blood bank. If you cannot do this because the patient is in the bathroom or the physician has to be notified of an elevated temperature, immediately return the blood to the blood bank, and retrieve it when you can administer it.

Question 69

The nurse is preparing to administer a unit of blood to a patient using blood tubing. On the blood product side of the Y tubing, she will hang blood. What will she hang on the other side of the Y tubing? a. Dextrose 5% b. Normal saline c. Dextrose 10% d. Dextrose 5%/normal saline

Answer 69

ANS: B Normal saline is compatible with blood products, unlike solutions that contain dextrose, which causes coagulation of donor blood.

Question 70

The nurse is administering blood. What should the nurse do to detect a blood reaction as quickly as possible? a. Remain with the patient during the first 15 minutes. b. Transfuse the blood at 10 mL/min. c. Monitor vital signs q 1 hour. d. Transfuse blood at 50 gtt/min.

Answer 70

ANS: A Remain with the patient during the first 15 minutes of a transfusion. Most transfusion reactions occur within the first 15 minutes of a transfusion. The initial flow rate during this time should be 2 mL/min, or 20 gtt/min. Initially infusing a small amount of blood component minimizes the volume of blood to which the patient is exposed, thereby minimizing the severity of a reaction. Monitor the patient’s vital signs at 5 minutes, at 15 minutes, and every 30 minutes until 1 hour after transfusion or per agency policy. Frequent monitoring of vital signs will help to quickly alert the nurse to a transfusion reaction

Question 71

An appropriate technique for the nurse to implement for a blood transfusion is to: a. provide medication through the IV line with the blood. b. regulate the flow of blood so that it infuses over 8 hours. c. clear the IV tubing with normal saline after the blood infuses. d. administer a blood product with clots through a filter line.

Answer 71

ANS: C After the blood has infused, clear the IV line with 0.9% normal saline and discard the blood bag according to agency policy. Medication should never be injected into the same IV line as a blood component because of the risk of contaminating the blood product with pathogens and the possibility of incompatibility. A separate IV line must be maintained if the patient requires IV infusion (total parenteral nutrition, pain control) during the transfusion. A unit of blood should not hang for longer than 4 hours because of the danger of bacterial growth. Check the appearance of blood product for leaks, bubbles, clots, or a purplish color. Do not transfuse blood if its integrity is compromised. Blood serves as a medium for bacteria.

Question 72

When a patient’s adverse reaction to a blood transfusion is differentiated, which of the following signs/symptoms indicates the presence of an anaphylactic response? a. Wheezing and chest pain b. Headache and muscle pain c. Hypotension and tingling of the extremities d. Crackles in the lungs and increased central venous pressure

Answer 72

ANS: A Observe the patient for wheezing, chest pain, and possible cardiac arrest. All of these are indications of an anaphylactic reaction. Be alert to patient complaints of headache or muscle pain in the presence of a fever. Both may be indicative of a febrile nonhemolytic reaction. Observe patients receiving massive transfusions for mild hypothermia, cardiac dysrhythmias, hypotension, and hypocalcemia. Cold blood products can affect the cardiac conduction system, resulting in ventricular dysrhythmias. Other cardiac dysrhythmias, hypotension, and tingling may indicate hypocalcemia, which occurs when citrate (used as a preservative for some blood products) combines with the patient’s calcium. Crackles in the bases of lungs and rising central venous pressure (CVP) are indications of circulatory overload.

Question 73

The patient is receiving a unit of packed RBCs. Fifteen minutes into the procedure, he complains of severe kidney pain, and his temperature increases by 3° F. The nurse stops the transfusion immediately, suspecting that which of the following reactions is occurring? a. Delayed hemolytic transfusion reaction b. Nonhemolytic febrile reaction c. Acute hemolytic transfusion reaction d. Severe allergic reaction

Answer 73

ANS: C Symptoms of an acute hemolytic reaction usually begin within 15 minutes of transfusion initiation and include severe pain in the kidney area and chest, increased temperature (up to 105° F), increased heart rate, and a sensation of heat and pain along the vein receiving blood, as well as chills, low back pain, headache, nausea, chest or back pain, chest tightness, dyspnea, bronchospasm, anxiety, hypotension, vascular collapse, disseminated intravascular coagulation, and possibly death. Symptoms of a delayed hemolytic reaction usually begin 2 to 14 days after the transfusion and include unexplained fever, an unexplained decrease in hemoglobin/hematocrit (Hgb/Hct), increased bilirubin levels, and jaundice. Symptoms of a nonhemolytic febrile reaction begin between 30 minutes after initiation and 6 hours after completion of transfusion and include fever greater than 1° C above baseline, flushing, chills, headache, and muscle pain; they occur most frequently in immunosuppressed patients. Symptoms of an acute severe allergic reaction usually begin within 5 to 15 minutes of initiation of transfusion and include coughing, nausea, vomiting, respiratory distress, wheezing, hypotension, loss of consciousness, and possible cardiac arrest.

Question 74

The patient has been home from the hospital for 10 days. On the last day of his hospitalization, he received 2 units of packed RBCs. This morning, he noticed that his skin had a yellow tint to it and his temperature was elevated. Which reaction might this patient be experiencing? a. Delayed hemolytic transfusion reaction b. Acute hemolytic transfusion reaction c. Nonhemolytic febrile reaction d. Severe allergic transfusion reaction

Answer 74

ANS: A Symptoms of a delayed hemolytic reaction usually begin 2 to 14 days after the transfusion and include unexplained fever, unexplained decrease in Hgb/Hct, increased bilirubin levels, and jaundice. Symptoms of an acute hemolytic reaction usually begin within 15 minutes of transfusion initiation and include severe pain in the kidney area and chest, increased temperature (up to 105° F), increased heart rate, and increased sensation of heat and pain along the vein receiving blood, as well as chills, low back pain, headache, nausea, chest or back pain, chest tightness, dyspnea, bronchospasm, anxiety, hypotension, vascular collapse, disseminated intravascular coagulation, and possibly death. Symptoms of a nonhemolytic febrile reaction begin between 30 minutes after initiation and 6 hours after completion of transfusion and include fever greater than 1° C above baseline, flushing, chills, headache, and muscle pain; they occur most frequently in immunosuppressed patients. Symptoms of an acute severe allergic reaction usually begin within 5 to 15 minutes of initiation of transfusion and include coughing, nausea, vomiting, respiratory distress, wheezing, hypotension, loss of consciousness, and possible cardiac arrest.

Question 75

The specific blood product used for replacement of clotting factors and fibrinogen is: a. whole blood. b. packed RBCs. c. cryoprecipitate. d. albumin, 25% pooled.

Answer 75

ANS: C Cryoprecipitate replaces factors VIII and XIII, von Willebrand’s factor, and fibrinogen. It also replaces red cell mass and plasma volume and is expected to raise hemoglobin by 1 g/100 mL and hematocrit by 3% in a nonhemorrhaging adult. Using cryoprecipitate is the preferred method of replacing red blood cell mass.

Question 76

The nurse is administering 1 unit of packed red blood cells as ordered by the primary care provider. While the nurse is measuring vital signs 15 minutes after starting the transfusion, the patient complains of chills and back pain. What is the nurse’s first action? a. Stop the blood transfusion and keep the vein patent by administering saline to infuse from the other side of the Y tubing. b. Slow the blood transfusion and notify the charge nurse. c. Disconnect the blood tubing from the catheter and replace it with an infusion of normal saline. d. Stop the blood transfusion and notify the primary care provider.

Answer 76

ANS: C The nurse’s first priority is to stop the blood transfusion. To keep the intravenous site patent, normal saline can be infused at a keep-open rate, but the tubing must be changed to avoid administering more blood as the saline flushes the blood from the tubing. If the tubing is not changed, additional blood will be administered, and the possible transfusion reaction will increase. The charge nurse or the primary care provider should be notified only after the patient has been assessed.

Question 77

Transfusion therapy is the intravenous (IV) administration of which of the following? (Select all that apply.) a. Whole blood b. Plasma products c. Red blood cells (RBCs) d. Platelets

Answer 77

ANS: A, B, C, D Transfusion therapy or blood replacement is the IV administration of whole blood, its components, or plasma-derived product for therapeutic purposes.

Question 78

What is the purpose of administering a transfusion? (Select all that apply.) a. Restore intravascular volume. b. Restore the oxygen-carrying capacity of blood. c. Provide clotting factors. d. Improve blood pressure.

Answer 78

ANS: A, B, C Transfusions are used to restore intravascular volume with whole blood or albumin, to restore the oxygen-carrying capacity of blood with RBCs, and to provide clotting factors and/or platelets. Although increasing blood volume may increase blood pressure, increasing blood pressure is not a primary objective of transfusion

Question 79

The patient is to receive 2 units of packed RBCs. Before administering the blood, what does the nurse need to do? (Select all that apply.) a. Insert an 18-gauge IV cannula. b. Have the patient complete a consent form. c. Obtain pretransfusion vital signs. d. Notify the physician for a temperature of 37° C.

Answer 79

ANS: B, C In emergency situations that require rapid transfusions, a large-gauge cannula is preferred; however, transfusions for therapeutic indications may be infused with cannulas ranging from 20 to 24 gauge. Check that the patient has properly completed and signed transfusion consent before retrieving blood. Most agencies require patients to sign consent forms before receiving blood component therapy because of the inherent risks. Obtain and record pretransfusion vital signs, including temperature, immediately before initiation of the transfusion. If the patient is febrile (temperature greater than 100° F [37.8° C]), notify the physician or the health care provider before initiating the transfusion. Change from baseline vital signs during infusion will alert the nurse to a potential transfusion reaction or adverse effect of therapy.

Question 80

The patient is receiving blood when he suddenly complains of low back pain and develops diaphoresis and chills. The nurse should: (Select all that apply.) a. stop the transfusion. b. start normal saline connected to the Y tubing. c. notify the physician. d. start normal saline using new IV tubing.

Answer 80

ANS: A, C, D If signs of a transfusion reaction occur, stop the transfusion, start normal saline with new primed tubing directly to the ventricular assist device (VAD) at the keep-vein-open rate (KVO), and notify the physician immediately

Question 81

Symptoms that indicate an adverse reaction to blood products include which of the following? (Select all that apply.) a. Fever b. Skin rash c. Hypotension d. Cardiac arrest

Answer 81

ANS: A, B, C, D | Symptoms that indicate an adverse reaction range from fever, chills, and skin rash to hypotension and cardiac arrest.

Question 82

A transfusion in which the donor is the patient is known as an ______________ transfusion or autotransfusion.

Answer 82

ANS: autologous In autologous transfusion, or autotransfusion, the donor is the patient.

Question 83

The presence or absence of specific antigens on the surface of red blood cells determines ___________________ in the ABO system.

Answer 83

ANS: blood type The presence or absence of specific antigens on the surface of red blood cells determines blood type in the ABO system.

Question 84

Antibodies that react against the A and B antigens are naturally present in the plasma of people whose red blood cells do not carry the antigen. These antibodies react against the foreign antigens. Incompatible red blood cells clump together or _____________, which results in a life-threatening hemolytic transfusion reaction.

Answer 84

ANS: agglutinate Antibodies that react against the A and B antigens are naturally present in the plasma of people whose red blood cells do not carry the antigen. These antibodies (agglutinins) react against the foreign antigens (agglutinogens). Incompatible red blood cells agglutinate (clump together), which results in a life-threatening hemolytic transfusion reaction.

Question 85

The nurse is caring for a patient who is receiving blood while monitoring the patient for potential complications. The nurse knows that a systemic response to administration of a blood product that is incompatible with the blood of the recipient, contains allergens to which the recipient is sensitive or allergic, or is contaminated with pathogens is known as a _________.

Answer 85

ANS: hemolytic reaction A hemolytic reaction is a systemic response to the administration of a blood product that is incompatible with the blood of the recipient, contains allergens to which the recipient is sensitive or allergic, or is contaminated with pathogens.

Question 86

The patient has received blood within the past 6 hours. The patient begins to feel short of breath and calls for the nurse. The nurse finds that the patient is dusky in color with crackles throughout his lungs and is coughing up pink frothy sputum. The nurse calls the physician immediately, knowing that the patient is showing signs of _________________.

Answer 86

ANS: transfusion-related acute lung injury (TRALI) Possible adverse outcomes that result from transfusion therapy include transmission of diseases, circulatory overload, and TRALI characterized by noncardiogenic pulmonary edema with onset within 6 hours of transfusion.

Question 87

Under the ABO system, the blood type __________ can be given to any individual and is known as the “Universal Donor.”

Answer 87

ANS: O negative O negative can be given to people of any blood type and is known as the “Universal Donor.”