Exam (elaborations)
NURSING 120 FINAL ADMINISTERING A BLOOD TRANSFUSION QUESTIONS AND ANSWERS WITH VERIFIED SOLUTIONS
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NURSING 120 FINAL ADMINISTERING A BLOOD TRANSFUSION QUESTIONS AND ANSWERS WITH VERIFIED SOLUTIONS
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NURSING 120 FINAL ADMINISTERING A BLOODTRANSFUSION QUESTIONS AND ANSWERS
WITH VERIFIED SOLUTIONS
obtain blood component from bank, Blood transfusion must be initiated within? -
ANSWER 30 minutes after release from laboratory or blood bank
check appearance of blood products for leaks, bubbles, clots, and purplish color. -
ANSWER Do not transfuse blood if integrity is compromised. Air bubbles, clots,
or discoloration indicate bacterial contamination or inadequate anticoagulation of
the stored component and are contraindications for transfusion of that products.
Blood serves as a medium for bacterial growth.
Verbally compare and correctly verify patient and blood product. Blood is double
checked with another person considered qualified by your agency. - ANSWER
Strict adherence to verification procedures before administration of blood or
blood components reduces the risk for administering the wrong blood to patient.
Step 1. transfusion record number and patients identification number match -
ANSWER prevents accidental administration of wrong components.
Step 2. patients name is correct on all documents. Check patients identification
number and date of birth on ID band and patient record. - ANSWER prevents
accidental administration of wrong components.
Step 3. check unit number on blood container with blood bank form to ensure
they are the same. - ANSWER Prevents accidental administration of wrong
components.
,Step 4. Blood type matches on transfusion record and blood bag. Verify that
component received from blood bank is the same component physician or health
care provider ordered - ANSWER Ensures patient receives correct therapy. One
of the most common causes of the patients receiving the incorrect transfusion is
obtaining the wrong blood components from the blood bank.
Step 5. Check the patients blood type and RH type are compatible with donor
blood type and Rh type - ANSWER Verifies accurate donor blood type and
compatibility
Step 6. Check expiration date and time on unit of blood. - ANSWER Never use
expired blood, because the cell components deteriorate and may contain excess
citrate ions
Step 7. Check patients first and last names by having patient state name, if able.
identify patient using at least 2 identifiers. when you notice a discrepancy during
verification procedure. Notify blood bank and appropriate personnel as indicated
by agency policy. Return blood to blood bank until discrepancy resolved. -
ANSWER At least 2 identifiers are required to administer blood.
Step 8. At the point of initiation, check the patients identification information with
the blood unit label information. Do not administer blood to a patient without an
identification bracelet - ANSWER Serves as the last point of patient and blood
confirmation and is the most important step in the verification process.
Step 9. Both individuals verifying the patient and unit identification record
verification process as directed by agency policy. - ANSWER Documentation is
the legal medical record.
, Review purpose of the transfusion, and ask patient to report any changes he or
she may feel during the transfusion. - ANSWER S\S of transfusion reactions
include chills, low back pain, shortness of breath, rash, hives, or itching
Empty urine drainage collection container, or have patient void. - ANSWER if a
transfusion reaction occurs, a urine specimen containing urine produced after
initiation of the transfusion will be sent to the laboratory.
Blood Administration: Perform hand hygiene, apply clean gloves and appropriate
attire. - ANSWER reduces risk for transmission of microorganisms.
Open Y- tubing blood administration set. - ANSWER Y - tubing facilitates
maintenance of IV access in case a patient will need more than 1 unit of blood.
Both a unit of blood and a container of normal saline are connected to the system.
Set all clamps to "OFF" position - ANSWER setting clamps to off position
prevents accidental spilling and wasting of products.
Spike 0.9% normal saline IV bag with one of Y - tubing spikes. Hang the bag on an
IV pole, and prime tubing. Open the upper clamp on normal saline side of tubing,
and squeeze the drip chamber until fluid covers the filter and 1/3 to 1/2 of the
drip chamber. - ANSWER Primes tubing with fluid to eliminate air in Y- tubing.
Closing the clamp prevents spillage and waste of fluid.
Maintain clamp on blood products side of Y- tubing in off position. Open common
tubing clamp to finish priming the clamp when tubing is filled with saline. All three
tubing clamps should be closed. Maintain protective sterile cap on tubing
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