Blood Administration NCLEX Practice
Questions, NUR 211 Blood Transfusion
NCLEX Questions, 1- blood nclex, 6-NCLEX
Medication IV Calculations, 5-Part 1
Medications Blood IV therapy PN NCLEX
Oct, 4-Module 8 Pharmacology and
Intravenous Therapies
Packed red blood cells have been prescribed for a client with low hemoglobin and
hematocrit levels. The nurse takes the client's temperature before hanging the blood
transfusion and records 100.6 F orally. Which action should the nurse take?
1) Begin the transfusion as prescribed.
2) Administer an antihistamine and begin the transfusion.
3) Delay hanging the blood and notify the health care provider.
4) Administer two tablets of acetaminophen (Tylenol) and begin the transfusion. - ANS;
3) Delay hanging the blood and notify the health care provider.
Rationale:
If the client has a temperature higher than 100 F, the unit of blood should not be hung
until the HCP is notified and has the opportunity to give further prescriptions. The HCP
likely will prescribe that the blood be administered regardless of the temperature, but
the decision is not within the nurse's scope of practice to make. The nurse needs an
HCP's prescription to administer medications to the client.
The nurse has received a prescription to transfuse a client with a unit of packed red
blood cells. Before explaining the procedure to the client, the nurse should ask which
INITIAL question?
1) "Have you ever had a transfusion before?"
2) "Why do you think that you need the transfusion?"
3) "Have you ever gone into shock for any reason in the past?"
4) "Do you know the complications and risks of a transfusion?" - ANS; 1) "Have you
ever had a transfusion before?"
Rationale:
,Asking the client about personal experience with transfusion therapy provides a good
starting point for client teaching about this procedure. Questioning about previous
history of shock and knowledge of complications and risks of transfusion are not helpful
because they may elicit a fearful response from the client. Although determining
whether the client knows the reason for the transfusion is important, it is not an
appropriate statement in terms of eliciting information from the client regarding an
understanding of the need for the transfusion.
A client receiving a transfusion of packed red blood cells (PRBCs) begins to vomit. The
client's blood pressure is 90/50 from a baseline of 125/78. The client's temperature is
100.8F orally from a baseline of 99.2F orally. The nurse determines that the client may
be experiencing which complication of a blood transfusion?
Rationale:
Septicemia occurs with the transfusion of blood contaminated with microorganisms.
Signs include CHILLS, FEVER, VOMITING, DIARRHEA, HYPOTENSION, and the
development of SHOCK.
Hyperkalemia causes weakness, paresthesias, abdominal cramps, diarrhea, and
dysrhythmias.
A delayed transfusion reaction can occur days to years after a transfusion. Signs
include fever, mild jaundice, and a decreased hematocrit level.
The nurse determines that a client is having a transfusion reaction. After the nurse
stops the transfusion, which action should be taken NEXT?
1) Remove the intravenous (IV) line.
2) Run a solution of 5% dextrose in water.
3) Run normal saline at a keep-vein-open rate.
4) Obtain a culture of the tip of the catheter device removed from the client. - ANS; 3)
Run normal saline at a keep-vein-open rate.
Rationale:
If the nurse suspects a transfusion reaction, the nurse stops the transfusion and infuses
normal saline at a keep-vein-open rate pending further health care provider
prescriptions. This maintains a patent IV access line and aids in maintaining the client's
intravascular volume.
,The nurse would NOT remove the IV line because then there would be no IV access
route.
Obtaining a culture of the tip of the catheter device removed from the client is incorrect.
First, the catheter should NOT be removed. Second, cultures are performed when
infection, NOT transfusion reactions, is suspected.
Normal saline is the solution of choice over solutions containing dextrose because
saline does not cause red blood cells to clump.
The nurse has just received a unit of packed red blood cells from the blood bank for
transfusion to an assigned client. The nurse is careful to select tubing especially made
for blood products, knowing that this tubing is manufactured with which item?
1) An air vent
2) Tinted tubing
3) An in-line filter
4) A microdrip chamber - ANS; 3) An in-line filter
Rationale:
The tubing used for blood administration has an in-line filter. The filter helps ensure that
any particles larger than the size of the filter are caught in the filter and are not infused
into the client.
Tinted tubing is incorrect because blood does not need to be protected from light.
The tubing should be macrodrip, not microdrip, to allow blood to flow freely through the
drip chamber.
An air vent is unnecessary because the blood bag is not made of glass.
The client has received a transfusion of platelets. The nurse evaluates that the client is
benefiting most from this therapy if the client exhibits which finding?
1) Increased hematocrit level
2) Increased hemoglobin level
3) Decline of elevated temperature to normal
4) Decreased oozing of blood from puncture sites and gums - ANS; 4) Decreased
oozing of blood from puncture sites and gums
Rationale:
Platelets are necessary for proper blood clotting. The client with insufficient platelets
may exhibit frank bleeding or oozing of blood from puncture sites, wounds, and mucous
membranes.
, Increased hemoglobin and hematocrit levels would occur when the client has received a
transfusion of red blood cells.
An elevated temperature would decline to normal after infusion of granulocytes if those
cells were instrumental in fighting infection in the body.
The nurse has obtained a unit of blood from the blood bank and has checked the blood
bag properly with another nurse. Just before beginning the transfusion, the nurse should
assess which PRIORITY item?
Rationale:
A change in vital signs during the transfusion from baseline may indicate that a
transfusion reaction is occurring. This is why the nurse assesses vital signs BEFORE
the procedure and again after the first 15 minutes. The other options do not identify
assessments that are a priority just before beginning a transfusion.
The nurse has just received a prescription to transfuse a unit of packed red blood cells
for an assigned client. Approximately how long will the nurse need to stay with the client
to ensure that a transfusion reaction is not occurring?
Rationale:
The nurse must remain with the client for the first 15 minutes of a transfusion, which is
usually when a transfusion reaction may occur. This enables the nurse to detect a
reaction and intervene quickly.
Following infusion of a unit of packed red blood cells, the client has developed new
onset of tachycardia, bounding pulses, crackles, and wheezes. Which action should the
nurse implement FIRST?
1) Maintain bed rest with legs elevated
2) Place the client in high-Fowler's position
3) Increase the rate of infusion of intravenous fluids
4) Consult with the HCP regarding initiation of oxygen therapy. - ANS; 2) Place the
client in high-Fowler's position
Rationale:
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