Review Blood transfusion

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Blood transfusion

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Question 1:

A nurse is preparing to administer a blood transfusion to a client. Which action should the nurse take before initiating the transfusion?

A. Confirm the client's identity and blood type with the client's family member. B. Obtain informed consent from the client and ensure the client has a signed consent form. C. Warm the blood unit to body temperature in a microwave oven to prevent hypothermia. D. Administer a rapid bolus of normal saline to prime the client's veins.

Answer and Explanation

Choice A:

Incorrect: Confirming the client's identity and blood type with the client's family member is not a reliable method for ensuring patient safety during a blood transfusion. The nurse should directly verify the client's identity and blood type with two unique identifiers, such as asking the client to state their full name and date of birth and comparing it to their identification band.

Choice B:

Correct: Obtaining informed consent from the client is a crucial step before initiating a blood transfusion. The nurse must ensure the client understands the risks and benefits of the transfusion and has willingly provided consent. A signed consent form is the formal documentation of this process.

Choice C:

Incorrect: Warming blood in a microwave oven is not an appropriate method for preventing hypothermia and can lead to hemolysis of the blood components. Blood should be warmed using an approved blood warmer designed for this purpose.

Choice D:

Incorrect: Administering a rapid bolus of normal saline is unnecessary and could lead to fluid overload in the client. The nurse should administer normal saline or another appropriate IV fluid at the prescribed rate if the client requires hydration before or after the transfusion, but not as a priming method.

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Question 2:

A client who received a blood transfusion 2 hours ago is now experiencing symptoms of a transfusion reaction, including fever, chills, and shortness of breath. What is the nurse's priority action?

A. Notify the healthcare provider immediately. B. Administer antipyretics to lower the client's fever. C. Prepare to administer a diuretic to manage fluid overload. D. Discontinue the blood transfusion immediately.

Answer and Explanation

Choice A:

Correct: In this situation, the nurse's priority action is to notify the healthcare provider immediately. The client is experiencing symptoms of a transfusion reaction, and prompt action is necessary to address the client's condition effectively.

Choice B:

Incorrect: Administering antipyretics may be appropriate to manage fever, but it is not the priority action. The nurse should first inform the healthcare provider about the transfusion reaction for further evaluation and instructions.

Choice C:

Incorrect: Preparing to administer a diuretic is not the priority action when a client shows symptoms of a transfusion reaction. Fluid overload is a potential complication of a transfusion reaction, but the immediate concern is addressing the reaction itself.

Choice D:

Incorrect: Discontinuing the blood transfusion is necessary in a transfusion reaction, but it is not the nurse's priority action. The nurse should first notify the healthcare provider, and then, based on their instructions, take appropriate steps to manage the client's reaction.

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Question 3:

A nurse is monitoring a client who is receiving a blood transfusion. After 15 minutes of starting the transfusion, the client develops hives, itching, and facial swelling. What is the nurse's immediate action?

A. Slow down the transfusion rate. B. Elevate the client's feet and lower the head. C. Discontinue the transfusion and infuse normal saline. D. Administer an antihistamine as prescribed.

Answer and Explanation

Choice A:

Incorrect: Slowing down the transfusion rate is not the appropriate action in this scenario. The client is experiencing signs of an allergic reaction, and the nurse must act promptly to address the situation.

Choice B:

Incorrect: Elevating the client's feet and lowering the head (Trendelenburg position) is not indicated for an allergic reaction. It may be used for clients in shock, but the priority is to manage the allergic reaction.

Choice C:

Correct: The nurse should immediately discontinue the transfusion and initiate the infusion of normal saline to maintain the client's intravascular volume. Discontinuing the blood transfusion helps prevent further exposure to the allergen (if an allergic reaction is confirmed) and addresses fluid volume needs.

Choice D:

Incorrect: While administering an antihistamine may be part of the treatment plan for an allergic reaction, it is not the immediate action. The nurse should first discontinue the transfusion and infuse normal saline as stated in option C.

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Question 4:

A client with a history of transfusion reactions requires a blood transfusion. Which blood component should the nurse ensure is transfused to minimize the risk of a future reaction?

A. Whole blood. B. Fresh frozen plasma (FFP). C. Packed red blood cells (PRBCs). D. Platelets.

Answer and Explanation

Choice A:

Incorrect: Transfusing whole blood increases the risk of adverse reactions and is not commonly used in modern transfusion practices. Whole blood is usually separated into its individual components for transfusion.

Choice B:

Incorrect: Fresh frozen plasma (FFP) contains various clotting factors and is used primarily to treat bleeding disorders and coagulopathies, not to prevent transfusion reactions.

Choice C:

Correct: Packed red blood cells (PRBCs) contain primarily red blood cells without significant amounts of plasma, white blood cells, or platelets. For clients with a history of transfusion reactions, PRBCs are the most suitable blood component to minimize the risk of future reactions.

Choice D:

Incorrect: Platelets are used to treat thrombocytopenia and platelet dysfunction but do not provide the main benefit of minimizing the risk of future transfusion reactions as PRBCs do.

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Question 5:

A client receiving a blood transfusion suddenly becomes agitated, dyspneic, and reports a sense of impending doom. The nurse assesses the client and notes jugular vein distention and muffled heart sounds. What action should the nurse take next?

A. Place the client in a supine position with legs elevated. B. Administer oxygen via a non-rebreather mask. C. Check the client's temperature and administer antipyretics if necessary. D. Stop the blood transfusion and notify the healthcare provider.

Answer and Explanation

Choice A:

Incorrect: Placing the client in a supine position with legs elevated is not appropriate in this situation. The client is showing signs of a potential severe allergic reaction (anaphylaxis) or a transfusion-related acute lung injury (TRALI), and the nurse should prioritize interventions accordingly.

Choice B:

Correct: Administering oxygen via a non-rebreather mask is the appropriate immediate action for a client experiencing respiratory distress and muffled heart sounds. This intervention helps improve oxygenation and respiratory function.

Choice C:

Incorrect: Checking the client's temperature and administering antipyretics is not indicated as the client's symptoms are not consistent with a fever. The focus should be on respiratory and cardiovascular support.

Choice D:

Incorrect: Stopping the blood transfusion is essential, but it is not the immediate action in this situation. The nurse's priority is to address the client's respiratory distress and ensure adequate oxygenation by administering oxygen, as stated in option B. Once the client is stable, the nurse should then notify the healthcare provider about the situation.Questions

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Question 6:

A nurse is caring for a client who has undergone major surgery and has a hemoglobin level of 8 g/dL. The client is experiencing symptoms of hypoxia, including tachycardia and shortness of breath. The nurse suspects the need for a blood transfusion. What action should the nurse take first?

A. Notify the healthcare provider immediately to obtain a blood transfusion order. B. Administer supplemental oxygen to the client to improve oxygenation. C. Initiate intravenous access with a large-bore catheter for possible transfusion. D. Encourage the client to ambulate to improve blood circulation.

Answer and Explanation

Choice A:

Notify the healthcare provider immediately to obtain a blood transfusion order – This is the priority action because the client’s hemoglobin level of 8 g/dL, along with symptoms of hypoxia, indicates a need for urgent medical intervention. Obtaining an order for a transfusion is crucial for addressing the underlying issue of low hemoglobin and associated hypoxia.

Choice B:

Administer supplemental oxygen to the client to improve oxygenation – While this action is important, it is not the first step. The low hemoglobin indicates a need for a transfusion, and notifying the provider can lead to quicker treatment.

Choice C:

Initiating intravenous access with a large-bore catheter is important to have in place if a blood transfusion is needed, as it allows for the rapid administration of blood products. However, this action should be done after obtaining the necessary order from the healthcare provider.

Choice D:

Encouraging the client to ambulate is not indicated in this situation, as the client is experiencing symptoms of hypoxia and anemia, which require prompt intervention through a blood transfusion if indicated.

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Question 7:

A nurse is preparing to administer a unit of packed red blood cells (PRBCs) to a client with severe anemia. Before starting the blood transfusion, the nurse should:

A. Obtain the client's informed consent for the blood transfusion. B. Confirm the client's blood type and Rh factor with the blood bank. C. Administer pre-medication to prevent transfusion reactions. D. Assess the client's blood pressure and heart rate.

Answer and Explanation

Choice A:

Obtaining the client's informed consent is a critical step before any medical procedure, including blood transfusions. This ensures the client understands the risks and benefits of the transfusion and gives their consent willingly.

Choice B:

Confirming the client's blood type and Rh factor with the blood bank is essential to prevent transfusion reactions. Mismatching blood types can lead to severe transfusion reactions and is a crucial step in the transfusion process.

Choice C:

Administering pre-medication to prevent transfusion reactions is not a standard practice. However, the nurse should assess the client for any risk factors or history of previous transfusion reactions to take appropriate precautions.

Choice D:

Assessing the client's blood pressure and heart rate is an important part of the overall assessment before the blood transfusion.

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Question 8:

A client receiving a blood transfusion suddenly develops chills, fever, and lower back pain. The nurse suspects a transfusion reaction. What is the nurse's priority action?

A. Stop the blood transfusion immediately. B. Notify the blood bank to request a new blood unit. C. Administer antipyretics to manage the client's fever. D. Place the client in a supine position with legs elevated.

Answer and Explanation

Choice A:

Stopping the blood transfusion immediately is the nurse's priority action if a transfusion reaction is suspected. This helps prevent further infusion of the potentially incompatible or problematic blood product.

Choice B:

Notifying the blood bank is essential to report the suspected transfusion reaction and to facilitate investigation and documentation. However, stopping the transfusion is the first step.

Choice C:

Administering antipyretics may help manage the client's fever, but it is not the nurse's priority action when a transfusion reaction is suspected.

Choice D:

Placing the client in a supine position with legs elevated is not a priority action when a transfusion reaction is suspected. The priority is to stop the transfusion and assess the client's vital signs and symptoms.

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Question 9:

A nurse is preparing to administer a platelet transfusion to a client with severe thrombocytopenia. The nurse should:

A. Infuse the platelets slowly over 4 hours. B. Use a standard IV infusion set for administration. C. Verify compatibility with the client's blood type. D. Warm the platelets to room temperature before infusion.

Answer and Explanation

Choice A:

Platelet transfusions should be administered quickly to minimize the risk of bacterial contamination and to prevent platelet clumping. They are usually infused over 15-30 minutes.

Choice B:

Using a standard IV infusion set for platelet administration is not recommended. Platelets are sensitive to certain infusion materials, and a specialized filter must be used to prevent the administration of platelet clumps.

Choice C:

Compatibility with the client's blood type is essential for red blood cell and plasma transfusions, but platelets do not require blood type matching. They are typically ABO compatible and Rh compatible.

Choice D:

Warming the platelets to room temperature before infusion is essential to prevent hypothermia in the client. Cold platelets can cause vasoconstriction and discomfort upon infusion.

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Question 10:

A client receiving a blood transfusion develops sudden chest pain, dyspnea, and a productive cough with pink, frothy sputum. The nurse suspects a severe transfusion reaction. What is the nurse's immediate action?

A. Raise the head of the client's bed and administer oxygen. B. Obtain a sputum sample for culture and sensitivity testing. C. Administer a diuretic to relieve pulmonary congestion. D. Discontinue the blood transfusion and remove the IV catheter.

Answer and Explanation

Choice A:

Raising the head of the client's bed and administering oxygen is the immediate action to improve oxygenation and relieve respiratory distress in a client experiencing potential pulmonary edema, as evidenced by the pink, frothy sputum.

Choice B:

Obtaining a sputum sample for culture and sensitivity testing may be important to assess for infection, but it is not the nurse's immediate action in response to a severe transfusion reaction.

Choice C:

Administering a diuretic may help with pulmonary congestion, but it is not the nurse's immediate action in response to a severe transfusion reaction. The priority is to improve oxygenation.

Choice D:

Discontinuing the blood transfusion and removing the IV catheter is important, but the immediate action to address the client's respiratory distress is to raise the head of the bed and administer oxygen. Stopping the transfusion can follow after the client's respiratory status stabilizes.Questions

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Question 11:

A nurse is preparing to administer a blood component to a client. Which blood component is responsible for promoting clot formation and controlling bleeding?

A. Fresh Frozen Plasma (FFP) B. Platelets C. Packed Red Blood Cells (PRBCs) D. Albumin

Answer and Explanation

Choice A:

Incorrect: Fresh Frozen Plasma (FFP) contains clotting factors and is used to treat bleeding disorders, but it is not primarily responsible for promoting clot formation and controlling bleeding.

Choice B:

Correct: Platelets are responsible for promoting clot formation and controlling bleeding. They play a crucial role in hemostasis and are used to treat thrombocytopenia and platelet dysfunction.

Choice C:

Incorrect: Packed Red Blood Cells (PRBCs) primarily carry oxygen and are used to treat anemia and improve oxygenation, but they do not have a direct role in clot formation or controlling bleeding.

Choice D:

Incorrect: Albumin is a protein used to expand intravascular volume, especially in cases of hypoalbuminemia, but it does not have a significant role in clot formation or controlling bleeding.

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Question 12:

A nurse is preparing to administer a blood product to a client with a clotting factor deficiency. Which blood product should the nurse anticipate administering?

A. Fresh Frozen Plasma (FFP) B. Platelets C. Cryoprecipitate D. Packed Red Blood Cells (PRBCs)

Answer and Explanation

Choice A:

Correct: Fresh Frozen Plasma (FFP) contains various clotting factors and is used to treat clotting factor deficiencies such as those found in coagulopathies or liver disease.

Choice B:

Incorrect: Platelets are used to treat thrombocytopenia and platelet dysfunction, not clotting factor deficiencies.

Choice C:

Incorrect: Cryoprecipitate is derived from FFP and contains concentrated fibrinogen and other clotting factors. It is used for specific clotting factor deficiencies but is not the primary treatment for clotting factor deficiencies in general.

Choice D:

Incorrect: Packed Red Blood Cells (PRBCs) are used to treat anemia and improve oxygenation but do not address clotting factor deficiencies.

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Question 13:

A client requires immediate volume replacement due to hypovolemic shock. Which blood product should the nurse anticipate administering to rapidly restore intravascular volume?

A. Fresh Frozen Plasma (FFP) B. Platelets C. Packed Red Blood Cells (PRBCs) D. Albumin

Answer and Explanation

Choice A:

Incorrect: Fresh Frozen Plasma (FFP) is not the appropriate blood product for immediate volume replacement. It contains clotting factors and is used to manage bleeding disorders.

Choice B:

Incorrect: Platelets are used to treat thrombocytopenia and platelet dysfunction and do not provide volume replacement.

Choice C:

Correct: Packed Red Blood Cells (PRBCs) contain red blood cells and are used for volume replacement in clients with acute blood loss or anemia.

Choice D:

Incorrect: Albumin is used for volume expansion in cases of hypoalbuminemia and fluid resuscitation in certain situations, but PRBCs are more effective for rapid volume replacement.

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Question 14:

A nurse is caring for a client with severe hypoalbuminemia. Which blood product should the nurse anticipate being prescribed to address the client's condition?

A. Fresh Frozen Plasma (FFP) B. Platelets C. Packed Red Blood Cells (PRBCs) D. Albumin

Answer and Explanation

Choice A:

Incorrect: Fresh Frozen Plasma (FFP) contains clotting factors and is not the primary treatment for hypoalbuminemia.

Choice B:

Incorrect: Platelets are used to treat thrombocytopenia and platelet dysfunction, not hypoalbuminemia.

Choice C:

Incorrect: Packed Red Blood Cells (PRBCs) are primarily used to improve oxygenation in anemic clients and do not address hypoalbuminemia.

Choice D:

Correct: Albumin is the blood product of choice for addressing severe hypoalbuminemia. It is a protein that helps maintain oncotic pressure and regulates fluid balance within the blood vessels.

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Question 15:

A client with severe liver disease has a decreased ability to synthesize clotting factors. Which blood product should the nurse anticipate being prescribed to manage the client's condition?

A. Fresh Frozen Plasma (FFP) B. Platelets C. Cryoprecipitate D. Packed Red Blood Cells (PRBCs)

Answer and Explanation

Choice A:

Correct: Fresh Frozen Plasma (FFP) contains various clotting factors and is used to manage clotting factor deficiencies, including those related to liver disease.

Choice B:

Incorrect: Platelets are used to treat thrombocytopenia and platelet dysfunction but do not primarily address clotting factor deficiencies caused by liver disease.

Choice C:

Incorrect: Cryoprecipitate is derived from FFP and contains concentrated fibrinogen and other clotting factors. It may be used in some cases of liver disease, but FFP is the more common choice for managing these conditions.

Choice D:

Incorrect: Packed Red Blood Cells (PRBCs) are used to improve oxygenation in anemic clients and are not the primary treatment for clotting factor deficiencies related to liver disease.Questions

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Question 16:

A nurse is preparing to initiate a blood transfusion for a client. Which action should the nurse take first to ensure client safety?

A. Verify the client's identity and blood type with two unique identifiers. B. Confirm the expiration date of the blood product. C. Assess the client's vital signs, including temperature, pulse, and blood pressure. D. Obtain informed consent from the client for the blood transfusion.

Answer and Explanation

Choice A:

Correct: The nurse should verify the client's identity and blood type with two unique identifiers, such as asking the client to state their full name and date of birth and comparing it to their identification band. This step ensures that the correct blood product is administered to the right client, promoting safety.

Choice B:

Incorrect: Confirming the expiration date of the blood product is important but not the first step in ensuring client safety during a blood transfusion. The nurse should first verify the client's identity and blood type.

Choice C:

Incorrect: Assessing the client's vital signs is essential, but it is not the first action to be taken. Verifying the client's identity and blood type is the priority before starting the transfusion.

Choice D:

Incorrect: Obtaining informed consent from the client is crucial but not the first action to be taken. The nurse should first verify the client's identity and blood type before seeking consent for the transfusion.

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Question 17:

A nurse is preparing to administer a blood transfusion to a client. Which vital sign alteration should the nurse report to the healthcare provider before initiating the transfusion?

A. Increase in blood pressure by 10 mmHg from the baseline. B. Respiratory rate of 22 breaths per minute. C. Heart rate decrease from 88 to 72 beats per minute. D. Temperature elevation to 38.5°C (101.3°F).

Answer and Explanation

Choice A:

Incorrect: A slight increase in blood pressure is not a significant vital sign alteration that requires immediate reporting before initiating the transfusion. It could be related to various factors, such as anxiety or pain.

Choice B:

Incorrect: A respiratory rate of 22 breaths per minute is within the normal range for an adult and does not require immediate reporting before starting the transfusion.

Choice C:

Incorrect: A decrease in heart rate from 88 to 72 beats per minute is not a critical vital sign alteration. As long as the heart rate remains within the client's baseline range, it does not need immediate reporting.

Choice D:

Correct: An elevated temperature of 38.5°C (101.3°F) may indicate a fever, which could be a sign of an infection or an adverse reaction to the transfusion. The nurse should report this vital sign alteration to the healthcare provider before proceeding with the transfusion to determine the appropriate course of action.

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Question 18:

A client is scheduled to receive a blood transfusion, but the nurse discovers that the blood product appears discolored or contains clots. What should the nurse do next?

A. Warm the blood product in a microwave oven to improve its condition. B. Administer the blood product as usual and monitor the client closely for reactions. C. Discard the blood product appropriately and notify the blood bank for a replacement. D. Filter the blood product through a standard IV filter to remove any clots.

Answer and Explanation

Choice A:

Incorrect: Warming the blood product in a microwave oven is not an appropriate action and could lead to hemolysis of the blood components. Blood should be warmed using an approved blood warmer designed for this purpose.

Choice B:

Incorrect: Administering a discolored blood product or one containing clots is unsafe and could cause harm to the client. The nurse should not proceed with the administration and should take appropriate actions.

Choice C:

Correct: If the nurse discovers that the blood product is discolored or contains clots, the nurse should discard the blood product appropriately and notify the blood bank immediately. This will ensure that the client receives a safe and suitable blood product for the transfusion.

Choice D:

Incorrect: Filtering the blood product through a standard IV filter is not sufficient to remove any clots present in the blood product. Using a blood product that appears abnormal could lead to adverse reactions in the client, so it is essential to obtain a replacement from the blood bank.

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Question 19:

A nurse is assessing a client's history before a blood transfusion. Which condition should the nurse identify as a contraindication for transfusion?

A. Iron-deficiency anemia B. Chronic kidney disease C. Hemolytic anemia D. Hypertension

Answer and Explanation

Choice A:

Incorrect: Iron-deficiency anemia is not a contraindication for a blood transfusion. In fact, it is one of the common indications for transfusion in clients with severe anemia.

Choice B:

Incorrect: Chronic kidney disease is not a contraindication for a blood transfusion. Transfusions may be necessary for clients with chronic kidney disease who develop anemia due to decreased erythropoietin production.

Choice C:

Correct: Hemolytic anemia is a contraindication for a blood transfusion. This condition involves the destruction of red blood cells, and a transfusion with incompatible blood can worsen the hemolysis and lead to a severe transfusion reaction.

Choice D:

Incorrect: Hypertension is not a contraindication for a blood transfusion. While the nurse should monitor blood pressure during the transfusion, hypertension alone does not preclude the need for a transfusion in a client with other indications for blood products.

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Question 20:

A client expresses anxiety and fear about receiving a blood transfusion. What action should the nurse take to address the client's concerns?

A. Explain the blood transfusion procedure in detail to the client. B. Offer the client a warm blanket to help them relax during the transfusion. C. Ask the healthcare provider to order a sedative for the client before the transfusion. D. Provide the client with information about the benefits and risks of the transfusion.

Answer and Explanation

Choice A:

Incorrect: While explaining the blood transfusion procedure is essential, doing so in excessive detail may increase the client's anxiety. The nurse should provide information in a clear and concise manner, addressing the client's specific concerns.

Choice B:

Incorrect: Offering a warm blanket is a comfort measure but may not be sufficient to address the client's anxiety and fear about the transfusion. The nurse should engage in therapeutic communication and provide emotional support.

Choice C:

Incorrect: Requesting a sedative for the client may not be the best course of action unless specifically prescribed by the healthcare provider. It is essential to explore other interventions to address the client's anxiety before resorting to medication.

Choice D:

Correct: Providing the client with information about the benefits and risks of the transfusion can help alleviate their anxiety and fear. The nurse should engage in patient education, discuss the purpose of the transfusion, potential benefits, and possible risks involved. This empowers the client with knowledge and helps them make informed decisions.

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Question 21:

A nurse is preparing to crossmatch blood for a client who requires a blood transfusion. Which blood component is involved in the crossmatching process?

A. Red blood cells. B. White blood cells. C. Platelets. D. Plasma.

Answer and Explanation

Choice A:

Correct: Red blood cells are the main blood component involved in the crossmatching process. Crossmatching ensures compatibility between the donor's red blood cells and the recipient's plasma, preventing adverse reactions during the transfusion.

Choice B:

Incorrect: White blood cells are not part of the crossmatching process. They play a role in the immune response but are not specifically assessed during crossmatching.

Choice C:

Incorrect: Platelets are not directly involved in the crossmatching process. Crossmatching primarily focuses on red blood cell compatibility.

Choice D:

Incorrect: Plasma is not directly involved in the crossmatching process. The focus is on ensuring compatibility between red blood cells and the recipient's plasma.

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Question 22:

A client with blood type B-positive (B+) requires a blood transfusion. Which blood types are compatible with this client for a crossmatch?

A. A-negative (A-), B-negative (B-), AB-positive (AB+), and O-positive (O+). B. A-positive (A+), AB-negative (AB-), O-positive (O+), and B-negative (B-). C. AB-negative (AB-), O-positive (O+), AB-positive (AB+), and B-positive (B+). D. A-positive (A+), O-negative (O-), B-positive (B+), and O-positive (O+).

Answer and Explanation

Choice A:

Incorrect: The client with blood type B-positive (B+) can receive blood from donors with B-positive (B+), O-positive (O+), AB-positive (AB+), and B-negative (B-). However, A-negative (A-) blood is not compatible with the client's B-positive blood type.

Choice B:

Incorrect: A-positive (A+), AB-negative (AB-), O-positive (O+), and B-negative (B-) blood types are not compatible with the client's B-positive (B+) blood type.

Choice C:

Correct: The client with blood type B-positive (B+) can receive blood from donors with AB-negative (AB-), O-positive (O+), AB-positive (AB+), and B-positive (B+). These blood types are compatible with the client's B-positive blood type.

Choice D:

Incorrect: The client with blood type B-positive (B+) can receive blood from donors with A-positive (A+), O-negative (O-), and O-positive (O+). However, B-positive (B+) blood is not compatible with the client's A-positive (A+) blood type.

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Question 23:

A nurse is reviewing a client's blood compatibility results before a blood transfusion. The crossmatch shows agglutination and incompatibility between the donor's red blood cells and the client's plasma. What action should the nurse take?

A. Administer the blood transfusion slowly to observe for any reactions. B. Discontinue the blood transfusion immediately and return the blood to the blood bank. C. Increase the infusion rate to flush out the incompatibility. D. Mix the incompatible blood with normal saline before transfusion.

Answer and Explanation

Choice A:

Incorrect: Administering the blood transfusion when agglutination and incompatibility are detected is unsafe and may lead to severe transfusion reactions. The nurse should not proceed with the transfusion.

Choice B:

Correct: In the presence of agglutination and incompatibility between the donor's red blood cells and the client's plasma, the nurse must discontinue the blood transfusion immediately and return the blood to the blood bank. This ensures the client's safety and prevents further adverse reactions.

Choice C:

Incorrect: Increasing the infusion rate will not resolve the incompatibility issue and may worsen the client's condition. The nurse should stop the transfusion promptly.

Choice D:

Incorrect: Mixing the incompatible blood with normal saline will not resolve the incompatibility issue and is not a safe practice. The nurse should not proceed with the transfusion and should return the blood to the blood bank.

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Question 24:

A nurse is preparing to crossmatch blood for a client with blood type O-negative (O-). Which blood type can safely receive blood from this client?

A. AB-positive (AB+). B. B-positive (B+). C. A-negative (A-). D. O-positive (O+).

Answer and Explanation

Choice A:

Incorrect: The client with blood type O-negative (O-) is considered the universal blood donor, and their blood can be safely transfused to individuals with any blood type. However, AB-positive (AB+) blood type cannot receive blood from O-negative (O-) donors due to ABO incompatibility.

Choice B:

Incorrect: B-positive (B+) blood type cannot receive blood from O-negative (O-) donors due to ABO incompatibility.

Choice C:

Incorrect: A-negative (A-) blood type cannot receive blood from O-negative (O-) donors due to ABO incompatibility.

Choice D:

Correct: O-positive (O+) blood type can safely receive blood from the client with blood type O-negative (O-) because O-negative (O-) is the universal blood donor for Rh-negative individuals.

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Question 25:

A client with blood type AB-positive (AB+) requires a blood transfusion. Which blood types can safely donate to this client?

A. A-negative (A-), B-negative (B-), AB-negative (AB-), and O-positive (O+). B. A-positive (A+), O-negative (O-), AB-negative (AB-), and B-positive (B+). C. A-negative (A-), B-positive (B+), AB-negative (AB-), and O-positive (O+). D. A-positive (A+), AB-positive (AB+), O-negative (O-), and B-negative (B-).

Answer and Explanation

Choice A:

Incorrect: The client with blood type AB-positive (AB+) is considered the universal blood recipient, as they can receive blood from any ABO blood group. However, O-positive (O+) blood type cannot donate to AB-positive (AB+) individuals due to ABO incompatibility.

Choice B:

Incorrect: B-positive (B+) blood type cannot donate to AB-positive (AB+) individuals due to ABO incompatibility.

Choice C:

Correct: A-negative (A-), AB-negative (AB-), and O-positive (O+) blood types can safely donate to the client with blood type AB-positive (AB+), as AB-positive (AB+) individuals can receive blood from any ABO blood group.

Choice D:

Incorrect: AB-positive (AB+) blood type cannot donate to AB-positive (AB+) individuals due to ABO incompatibility.Questions

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Question 26:

A nurse is assessing a client who just received a blood transfusion. The client complains of back pain, fever, and chills. What action should the nurse take first?

A. Notify the healthcare provider immediately. B. Administer acetaminophen to reduce the fever. C. Stop the transfusion and disconnect the IV tubing. D. Infuse normal saline to maintain the client's hydration.

Answer and Explanation

Choice A:

Correct: The client's symptoms, including back pain, fever, and chills, indicate a potential transfusion reaction. The nurse's first action should be to notify the healthcare provider immediately for further evaluation and intervention.

Choice B:

Incorrect: While administering acetaminophen may be appropriate to reduce fever, it is not the first action the nurse should take when suspecting a transfusion reaction. The priority is to stop the transfusion and notify the healthcare provider.

Choice C:

Incorrect: Stopping the transfusion and disconnecting the IV tubing is the appropriate action for a suspected transfusion reaction, but it should not be the first step. The nurse should first notify the healthcare provider to obtain further instructions.

Choice D:

Incorrect: Infusing normal saline to maintain hydration is important, but it is not the first action the nurse should take when a transfusion reaction is suspected. The nurse should first stop the transfusion and notify the healthcare provider.

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Question 27:

A client develops respiratory distress and chest pain during a blood transfusion. The nurse suspects a transfusion-related acute lung injury (TRALI). What is the nurse's priority intervention?

A. Administering oxygen via a non-rebreather mask. B. Discontinuing the blood transfusion immediately. C. Elevating the client's feet and lowering the head. D. Administering diuretics to manage fluid overload.

Answer and Explanation

Choice A:

Correct: The client's symptoms of respiratory distress and chest pain indicate a potential transfusion-related acute lung injury (TRALI), a severe transfusion reaction. The nurse's priority intervention is to administer oxygen via a non-rebreather mask to improve oxygenation.

Choice B:

Incorrect: Discontinuing the blood transfusion immediately is necessary in suspected cases of TRALI, but it is not the priority intervention. First, the nurse should provide immediate respiratory support by administering oxygen.

Choice C:

Incorrect: Elevating the client's feet and lowering the head (Trendelenburg position) is not indicated for TRALI. It may be used for clients in shock, but the priority is to manage the client's respiratory distress and chest pain.

Choice D:

Incorrect: Administering diuretics is not the priority intervention for TRALI. TRALI is caused by a reaction to plasma components, not fluid overload, and diuretics may not address the underlying cause.

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Question 28:

A nurse is caring for a client who experiences an acute hemolytic transfusion reaction. What intervention should the nurse anticipate implementing?

A. Administering antipyretics to reduce fever. B. Preparing to administer a diuretic to manage fluid overload. C. Monitoring the client's vital signs frequently. D. Administering epinephrine to counteract an allergic reaction.

Answer and Explanation

Choice A:

Incorrect: Administering antipyretics to reduce fever is not the appropriate intervention for an acute hemolytic transfusion reaction. This type of reaction involves the destruction of red blood cells, not an elevation in body temperature.

Choice B:

Incorrect: Preparing to administer a diuretic is not the appropriate intervention for an acute hemolytic transfusion reaction. Fluid overload is not a typical feature of this type of reaction.

Choice C:

Correct: Monitoring the client's vital signs frequently is a crucial intervention for an acute hemolytic transfusion reaction. This type of reaction can cause rapid onset of severe symptoms, including fever, chills, hypotension, tachycardia, and potential shock.

Choice D:

Incorrect: Administering epinephrine is not the appropriate intervention for an acute hemolytic transfusion reaction. Epinephrine is used to treat anaphylactic reactions, not hemolytic reactions.

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Question 29:

A nurse is caring for a client who develops urticaria (hives) and itching during a blood transfusion. The nurse suspects an allergic transfusion reaction. What is the appropriate nursing action?

A. Administer epinephrine immediately. B. Stop the transfusion and disconnect the IV tubing. C. Slow down the transfusion rate. D. Obtain a blood sample for repeat crossmatching.

Answer and Explanation

Choice A:

Incorrect: Administering epinephrine is not the appropriate intervention for an allergic transfusion reaction characterized by urticaria and itching. Epinephrine is used to treat anaphylactic reactions.

Choice B:

Incorrect: Stopping the transfusion and disconnecting the IV tubing is appropriate in the event of an allergic transfusion reaction, but it should not be the first action. The nurse should first slow down or stop the transfusion if mild symptoms are present and notify the healthcare provider for further instructions.

Choice C:

Correct: Slowing down the transfusion rate may be appropriate for mild allergic reactions to reduce symptoms. However, if the reaction worsens, the nurse should stop the transfusion immediately.

Choice D:

Incorrect: Obtaining a blood sample for repeat crossmatching is not indicated in an allergic transfusion reaction. Allergic reactions are related to hypersensitivity to plasma proteins and do not involve compatibility issues between red blood cells and plasma.Questions

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Question 30:

A nurse is monitoring a client who just received a blood transfusion. The client suddenly develops dyspnea, tachycardia, and chest pain. What is the nurse's priority action?

A. Elevate the head of the bed to promote lung expansion. B. Administer diuretics to manage fluid overload. C. Stop the transfusion immediately and notify the healthcare provider. D. Document the client's symptoms and continue the transfusion at a slower rate.

Answer and Explanation

Choice A:

Incorrect: Elevating the head of the bed may help promote lung expansion, but it is not the nurse's priority action when the client is experiencing severe symptoms like dyspnea, tachycardia, and chest pain during a transfusion.

Choice B:

Incorrect: Administering diuretics is not the appropriate action for the client's symptoms, which suggest a possible transfusion-related acute lung injury (TRALI) or acute hemolytic transfusion reaction. Diuretics will not address the underlying cause.

Choice C:

Correct: The client's symptoms of dyspnea, tachycardia, and chest pain indicate a potential severe transfusion reaction. The nurse's priority action is to stop the transfusion immediately and notify the healthcare provider for further evaluation and intervention.

Choice D:

Incorrect: Continuing the transfusion at a slower rate is not appropriate when the client is experiencing severe symptoms. The nurse should first stop the transfusion and then notify the healthcare provider.

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Question 31:

A nurse is providing post-transfusion care to a client who just received a blood transfusion. Which assessment finding should the nurse report to the healthcare provider immediately?

A. Mild itching on the client's forearms. B. Mild lower back pain that subsides. C. Blood pressure increase by 10 mmHg from baseline. D. Hemoglobin level increase by 2 g/dL after the transfusion.

Answer and Explanation

Choice A:

Incorrect: Mild itching on the client's forearms is a common and expected side effect of a blood transfusion and may not require immediate reporting to the healthcare provider.

Choice B:

Incorrect: Mild lower back pain that subsides is not a significant finding and may not require immediate reporting to the healthcare provider.

Choice C:

Correct: An increase in blood pressure by 10 mmHg from the client's baseline may indicate a potential transfusion reaction or fluid overload. The nurse should report this finding to the healthcare provider for further evaluation.

Choice D:

Incorrect: An increase in hemoglobin level by 2 g/dL after the transfusion is a positive outcome, indicating a successful transfusion. There is no need to report this finding to the healthcare provider.

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Question 32:

A client received a blood transfusion 2 hours ago. The nurse is assessing for signs of a delayed transfusion reaction. Which assessment finding should the nurse report to the healthcare provider?

A. Client reports mild headache. B. Client has slightly elevated temperature. C. Client's skin appears pale and cool to touch. D. Client experiences generalized muscle weakness.

Answer and Explanation

Choice A:

Incorrect: A mild headache is a common and expected side effect of a blood transfusion and may not require immediate reporting to the healthcare provider.

Choice B:

Correct: A slightly elevated temperature in a client who received a blood transfusion 2 hours ago could indicate a delayed transfusion reaction. The nurse should report this finding to the healthcare provider for further evaluation.

Choice C:

Incorrect: Pale and cool skin may be an expected finding in a client who received a blood transfusion, especially if they experienced a rapid transfusion or had a reaction. However, it is not the priority finding to report.

Choice D:

Incorrect: Generalized muscle weakness may occur for various reasons and may not be directly related to a delayed transfusion reaction. The nurse should prioritize reporting the slightly elevated temperature.

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Question 33:

A nurse is monitoring a client during a blood transfusion. The client suddenly develops hives, itching, and facial swelling. What is the nurse's immediate action?

A. Stop the transfusion immediately and notify the healthcare provider. B. Administer an antihistamine to manage the allergic reaction. C. Slow down the transfusion rate to observe for further reactions. D. Place the client in a supine position with legs elevated.

Answer and Explanation

Choice A:

Correct: The client's symptoms of hives, itching, and facial swelling indicate a potential allergic transfusion reaction (urticarial reaction). The nurse's immediate action is to stop the transfusion immediately and notify the healthcare provider for further evaluation and intervention.

Choice B:

Incorrect: While administering an antihistamine may be part of the treatment plan for an allergic transfusion reaction, it is not the immediate action. The nurse should first stop the transfusion and notify the healthcare provider.

Choice C:

Incorrect: Slowing down the transfusion rate is not appropriate in the presence of an allergic transfusion reaction. The nurse should stop the transfusion immediately.

Choice D:

Incorrect: Placing the client in a supine position with legs elevated is not indicated for an allergic transfusion reaction. It may be used for clients in shock, but the priority is to manage the allergic reaction.

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Question 34:

A client received a blood transfusion 4 hours ago and now reports feeling lightheaded and dizzy. The nurse notes a drop in blood pressure and an increase in heart rate. What intervention should the nurse implement first?

A. Administer a bolus of normal saline. B. Elevate the client's feet and lower the head. C. Check the client's hemoglobin and hematocrit levels. D. Notify the healthcare provider for further evaluation.

Answer and Explanation

Choice A:

Incorrect: Administering a bolus of normal saline may help increase intravascular volume, but it is not the first intervention to be implemented. The nurse should first identify the cause of the client's symptoms and take appropriate actions.

Choice B:

Correct: The client's symptoms of feeling lightheaded and dizzy, along with a drop in blood pressure and an increase in heart rate, suggest orthostatic hypotension. The nurse's first intervention should be to elevate the client's feet and lower the head to improve blood flow to the brain.

Choice C:

Incorrect: Checking the client's hemoglobin and hematocrit levels is essential but may not be the first intervention in this situation. The client's symptoms indicate an immediate need to address the orthostatic hypotension.

Choice D:

Incorrect: Notifying the healthcare provider for further evaluation is important, but it may not be the first intervention. The nurse should first take immediate actions to address the client's symptoms of orthostatic hypotension.Questions

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Question 35:

A nurse is preparing to administer a blood transfusion to a client. What is the nurse's priority action to prevent a potential complication related to blood compatibility?

A. Obtain a signed informed consent from the client. B. Confirm the client's blood type and Rh factor with two unique identifiers. C. Ensure that the blood product is properly labeled and has not expired. D. Assess the client's vital signs and baseline laboratory values.

Answer and Explanation

Choice A:

Incorrect: Obtaining a signed informed consent is an essential step before administering a blood transfusion, but it is not the priority action for preventing a potential complication related to blood compatibility. The nurse should first confirm the client's blood type and Rh factor.

Choice B:

Correct: The nurse's priority action is to confirm the client's blood type and Rh factor with two unique identifiers to ensure compatibility between the client and the blood product. This step is crucial for preventing transfusion reactions due to ABO and Rh incompatibility.

Choice C:

Incorrect: Ensuring that the blood product is properly labeled and has not expired is important for patient safety but is not the priority action before administering a blood transfusion. The nurse should first confirm the client's blood type and Rh factor.

Choice D:

Incorrect: Assessing the client's vital signs and baseline laboratory values is essential, but it is not the priority action for preventing a potential complication related to blood compatibility. The nurse should first confirm the client's blood type and Rh factor.

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Question 36:

A nurse is caring for a client who is about to receive a blood transfusion. What information should the nurse provide to the client to prevent an allergic transfusion reaction?

A. "You may experience a mild fever and chills during the transfusion, which is normal." B. "If you develop any itching, rash, or facial swelling, please notify me immediately." C. "Expect a brief period of increased heart rate after the transfusion is completed." D. "It is common to have lower back pain after receiving a blood transfusion."

Answer and Explanation

Choice A:

Incorrect: Fever and chills during a blood transfusion may be signs of a febrile transfusion reaction, not an allergic reaction. The nurse should provide information specific to preventing allergic reactions.

Choice B:

Correct: Itching, rash, and facial swelling are common signs of an allergic transfusion reaction. The nurse should instruct the client to notify the healthcare provider immediately if they experience these symptoms.

Choice C:

Incorrect: A brief period of increased heart rate after the transfusion may be normal, but it is not specific to preventing an allergic transfusion reaction. The nurse should focus on providing information about allergic reaction symptoms.

Choice D:

Incorrect: Lower back pain is not typically associated with allergic transfusion reactions. The nurse should provide information about symptoms that indicate an allergic reaction, such as itching, rash, and facial swelling.

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Question 37:

A client has a history of severe allergic reactions and is scheduled to receive a blood transfusion. What intervention should the nurse implement to prevent an allergic transfusion reaction in this client?

A. Pre-medicate the client with antihistamines before the transfusion. B. Administer the blood transfusion rapidly to minimize exposure. C. Ensure that the blood product is warmed before administration. D. Monitor the client's vital signs frequently during the transfusion.

Answer and Explanation

Choice A:

Correct: Pre-medicating the client with antihistamines before the transfusion can help prevent or minimize allergic transfusion reactions in clients with a history of severe allergies. Antihistamines block histamine release, reducing the risk of allergic symptoms.

Choice B:

Incorrect: Administering the blood transfusion rapidly is not a preventive measure for allergic transfusion reactions. In fact, rapid administration may increase the risk of adverse reactions.

Choice C:

Incorrect: Warming the blood product before administration is important to prevent hypothermia but is not directly related to preventing allergic transfusion reactions.

Choice D:

Incorrect: Monitoring the client's vital signs during the transfusion is a standard practice, but it is not the primary intervention for preventing allergic transfusion reactions. Pre-medication with antihistamines is a more targeted approach.

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Question 38:

A client is receiving a blood transfusion, and the nurse suspects a transfusion-related acute lung injury (TRALI) due to sudden respiratory distress. What action should the nurse take to prevent further complications?

A. Increase the rate of the blood transfusion to complete it quickly. B. Administer oxygen via a nasal cannula or face mask. C. Place the client in a supine position with legs elevated. D. Restart the transfusion with a different blood product.

Answer and Explanation

Choice A:

Incorrect: Increasing the rate of the blood transfusion is not the appropriate action when the client is experiencing respiratory distress. Rapid transfusion may exacerbate the TRALI and lead to further complications.

Choice B:

Correct: Administering oxygen via a nasal cannula or face mask is a priority action for a client experiencing respiratory distress. Providing supplemental oxygen can help improve oxygenation and prevent further complications.

Choice C:

Incorrect: Placing the client in a supine position with legs elevated is not the appropriate action for a client with respiratory distress. This position may worsen the client's breathing difficulties.

Choice D:

Incorrect: Restarting the transfusion with a different blood product is not indicated in the presence of suspected TRALI. The nurse's priority is to manage the client's respiratory distress and discontinue the transfusion if necessary.

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Question 39:

A nurse is caring for a client who experienced a mild allergic reaction during a blood transfusion. Which action should the nurse take to prevent future allergic reactions in this client?

A. Discontinue the blood transfusion immediately. B. Administer an antihistamine to manage the current reaction. C. Notify the healthcare provider for further evaluation. D. Obtain a sample for repeat crossmatching.

Answer and Explanation

Choice A:

Incorrect: Discontinuing the blood transfusion may be necessary if the allergic reaction is severe, but it is not the appropriate action for a mild allergic reaction. The nurse should manage the current reaction and take preventive measures for future transfusions.

Choice B:

Incorrect: Administering an antihistamine is appropriate to manage the current allergic reaction, but it may not prevent future allergic reactions. The nurse should focus on preventing allergic reactions in future transfusions.

Choice C:

Incorrect: Notifying the healthcare provider is important for appropriate management, but it may not directly prevent future allergic reactions. The nurse should implement preventive measures.

Choice D:

Correct: Obtaining a sample for repeat crossmatching is essential to identify and select blood products that are less likely to cause an allergic reaction in the client. This step can help prevent future allergic transfusion reactions and ensure safer blood product selection.

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