Final Review- Blood Flashcards
Q: A client receiving a blood transfusion develops anxiety and low back pain. After stopping the transfusion, what action by the nurse is most important?
a. Documenting the events in the client’s medical record
b. Double-checking the client and blood product identification
c. Placing the client on strict bedrest until the pain subsides
d. Reviewing the client’s medical record for known allergies
B
Q: A patient in the emergency department complains of back pain and difficulty breathing 15 minutes after a transfusion of packed red blood cells is started. The nurse’s first action should be to
a.
administer oxygen therapy at a high flow rate.
b.
obtain a urine specimen to send to the laboratory.
c.
notify the health care provider about the symptoms.
d.
disconnect the transfusion and infuse normal saline.
D
The patient’s symptoms indicate a possible acute hemolytic reaction caused by the transfusion. The first action should be to disconnect the transfusion and infuse normal saline. The other actions also are needed but are not the highest priority.
Q: A nurse is preparing to administer a blood transfusion. What action is most important?
a. Correctly identifying client using two identifiers
b. Ensuring informed consent is obtained if required
c. Hanging the blood product with Ringer’s lactate
d. Staying with the client for the entire transfusion
B
If the facility requires informed consent for transfusions, this action is most important because it precedes the other actions taken during the transfusion. Correctly identifying the client and blood product is a National Patient Safety Goal, and is the most important action after obtaining informed consent. Ringer’s lactate is not used to transfuse blood. The nurse does not need to stay with the client for the duration of the transfusion.
Q: A nurse is preparing to hang a blood transfusion. Which action is most important?
a. Documenting the transfusion
b. Placing the client on NPO status
c. Placing the client in isolation
d. Putting on a pair of gloves
- To prevent bloodborne illness, the nurse should don
D
a pair of gloves prior to hanging the blood. Documentation is important but not the priority at this point. NPO status and isolation are not needed.
Q: A student nurse is helping a registered nurse with a blood transfusion. Which actions by the student are most appropriate? (Select all that apply.)
a. Hanging the blood product using normal saline and a filtered tubing set
b. Taking a full set of vital signs prior to starting the blood transfusion
c. Telling the client someone will remain at the bedside for the first 5 minutes
d. Using gloves to start the client’s IV if needed and to handle the blood product
e. Verifying the client’s identity, and checking blood compatibility and expiration time
A,B,D
Correct actions prior to beginning a blood transfusion include hanging the product with saline and the correct filtered blood tubing, taking a full set of vital signs prior to starting, and using gloves. Someone stays with the client for the first 15 to 30 minutes of the transfusion. Two registered nurses must verify the client’s identity and blood compatibility.
A student nurse is learning about blood transfusion compatibilities. What information does this include? (Select all that apply.)
a. Donor blood type A can donate to recipient blood type AB.
b. Donor blood type B can donate to recipient blood type O.
c. Donor blood type AB can donate to anyone.
d. Donor blood type O can donate to anyone.
e. Donor blood type A can donate to recipient blood type B.
Blood type A can be donated to people who have blood types A or AB. Blood type O can be given to anyone. Blood type B can be donated to people who have blood types B or AB. Blood type AB can only go to recipients with blood type AB.
Q: A client in sickle cell crisis is dehydrated and in the emergency department. The nurse plans to start an IV. Which fluid choice is best?
a. 0.45% normal saline
b. 0.9% normal saline
c. Dextrose 50% (D50)
d. Lactated Ringer’s solution
A.
Because clients in sickle cell crisis are often dehydrated, the fluid of choice is a hypotonic solution such as 0.45% normal saline. 0.9% normal saline and lactated Ringer’s solution are isotonic. D50 is hypertonic and not used for hydration.
A patient undergoing a hip replacement has autologous blood on standby if a transfusion is needed. What is the primary advantage of autologous transfusions?
A) Safe transfusion for patients with a history of transfusion reactions
B) Prevention of viral infections from another person’s blood
C) Avoidance of complications in patients with alloantibodies
D) Prevention of alloimmunization
B.
Feedback: The primary advantage of autologous transfusions is the prevention of viral infections from another person’s blood. Other advantages include safe transfusion for patients with a history of transfusion reactions, prevention of alloimmunization, and avoidance of complications in patients with alloantibodies.
: A client has thrombocytopenia. What client statement indicates the client understands self-management of this condition?
a. “I brush and use dental floss every day.”
b. “I chew hard candy for my dry mouth.”
c. “I usually put ice on bumps or bruises.”
d. “Nonslip socks are best when I walk.”
-
C
The client should be taught to apply ice to areas of minor trauma. Flossing is not recommended. Hard foods should be avoided. The client should wear well-fitting shoes when ambulating.
(11) Platelet transfusion less than 10,000 is a
life-threatening situation
A 19-year-old woman with immune thrombocytopenic purpura (ITP) has an order for a platelet transfusion. Which information indicates that the nurse should consult with the health care provider before obtaining and administering platelets? a. The platelet count is 42,000/⎧L. b. Petechiae are present on the chest. c. Blood pressure (BP) is 94/56 mm Hg. d. Blood is oozing from the venipuncture site.
A
Platelet transfusions are not usually indicated until the platelet count is below 10,000 to 20,000/⎧L unless the patient is actively bleeding. Therefore the nurse should clarify the order with the health care provider before giving the transfusion. The other data all indicate that bleeding caused by ITP may be occurring and that the platelet transfusion is appropriate.
Splenectomy has a high risk for infection and you want them to have a vaccination done
two weeks before and after
When a patient with splenomegaly is scheduled for splenectomy, which action will the nurse include in the preoperative plan of care?
a.
Discourage deep breathing to reduce risk for splenic rupture.
b.
Teach the patient to use ibuprofen (Advil) for left upper quadrant pain.
c.
Schedule immunization with the pneumococcal vaccine (Pneumovax).
d.
Avoid the use of acetaminophen (Tylenol) for 2 weeks prior to surgery.
C
Asplenic patients are at high risk for infection with Pneumococcus and immunization reduces this risk. There is no need to avoid acetaminophen use before surgery, but nonsteroidal antiinflammatory drugs (NSAIDs) may increase bleeding risk and should be avoided. The enlarged spleen may decrease respiratory depth and the patient should be encouraged to take deep breaths.
: A client with autoimmune idiopathic thrombocytopenic purpura (ITP) has had a splenectomy and returned to the surgical unit 2 hours ago. The nurse assesses the client and finds the abdominal dressing saturated with blood. What action is most important?
a. Preparing to administer a blood transfusion
b. Reinforcing the dressing and documenting findings
c. Removing the dressing and assessing the surgical site
d. Taking a set of vital signs and notifying the surgeon
D
- While some bloody drainage on a new surgical dressing is expected, a saturated dressing is not. This client is already at high risk of bleeding due to the ITP. The nurse should assess vital signs for shock and notify the surgeon immediately. The client may or may not need a transfusion. Reinforcing the dressing is an appropriate action, but the nurse needs to do more than document afterward. Removing the dressing increases the risk of infection; plus, it is not needed since the nurse knows where the bleeding is coming from.
Q: Which problem reported by a patient with hemophilia is most important for the nurse to communicate to the physician? a. Leg bruises b. Tarry stools c. Skin abrasions d. Bleeding gums
B
Melena is a sign of gastrointestinal bleeding and requires collaborative actions such as checking hemoglobin and hematocrit and administration of coagulation factors. The other problems indicate a need for patient teaching about how to avoid injury, but are not indicators of possible serious blood loss.
A patient with hemophilia is admitted with acute bleeding. Until the cause of the bleeding is determined, the nurse should be prepared to perform which intervention?
- infusing packed red blood cells
- infusing normal saline
- infusing heparin
- infusing fresh-frozen plasma
Global Rationale: Fresh-frozen plasma replaces all clotting factors except platelets. When the cause of bleeding is not yet determined, fresh-frozen plasma may be administered intravenously until a definitive diagnosis is made. Red packed cells and normal saline would increase volume but would not replace the clotting factors. Heparin would be contraindicated as it would promote further bleeding.
