A client is admitted to the intensive care unit with thrombocytopenia. The client's platelet count is 120,000 μl. The health care provider ordered 5 bags of platelets to be infused on this client. How long should the nurse infuse each bag of platelets?
a. 5 - 10 minutes
b. 10 - 20 minutes
c. ...
A client is admitted to the intensive care unit with thrombocytopenia. The client's
platelet count is 120,000 μl. The health care provider ordered 5 bags of platelets
to be infused on this client. How long should the nurse infuse each bag of
platelets?
a. 5 - 10 minutes
b. 10 - 20 minutes
c. 20 - 30 minutes
d. 30 - 60 minutes - ANSWER- d. 30 - 60 minutes
Rationale:
Thrombocytopenia means that a client's platelet count is less than 150,000
platelets per microliter. A normal client's platelet count varies from 150,000 to
450,000 per microliter. Platelets are responsible to stop bleeding by forming
clumps or plugs during blood vessel insults. Platelets are usually infused
between 30 to 60 minutes. With each unit of platelets, the client's platelet count
may be increased about 6000 μl.
A client arrives at the emergency department with a hemoglobin of 6. The health
care provider orders 2 units of packed red blood cells (PRBCs) to be infused each
over 4 hours. The nurse starts the first unit of PRBCs and within the first 15
minutes, the client begins to flush, redness to the face, and begins itching. Which
type of infusion reaction is the client exhibiting?
a. Febrile reaction.
b. Anaphylactic reaction.
c. Circulatory overload.
d. Hemolytic reaction. - ANSWER- a. Febrile reaction.
Rationale:
When a client has a febrile reaction, the client has flushing, redness, and itchy
skin. Usually, the health care provider will order tylenol and benadryl for the
, client and continue the transfusion. When a client has a hemoglobin of less than
7, the client is very sick and could go to heaven without an intervention. One unit
of PRBCs will increase the hemoglobin 1 point after transfusion.
The nurse is starting a client's 3rd unit of PRBCs. The client begins complaining
of severe back pain, becomes apprehensive, and VS: T 100.9F, P 126, RR 28, BP
80/54. Which intervention should the nurse perform as priority?
a. Administer tylenol and benadryl and continue the infusion.
b. Slow the infusion because the client is in circulatory overload.
c. Stop the infusion because the client is having a hemolytic reaction.
d. Stop the infusion because the client is having an anaphylactic reaction. -
ANSWER- c. Stop the infusion because the client is having a hemolytic reaction.
Rationale:
When a client has a hemolytic reaction, the client's immune system destroys the
red blood cells administered during the transfusion. This process of destruction
is called hemolysis. The client's symptoms may include lower back pain,
apprehension, fever, tachycardia, and hypotension. The priority is to stop the
infusion, call the health care provider, get labs drawn, and collect a urine
specimen. Treatment of such a reaction is aimed at protecting the client's renal
function, so IV fluids will be administered, intake and output will be closely
monitored to ensure urine output is 100 ml/hr, and diuretics will be administered.
An outpatient comes to the clinic for 2 units of blood. In the first 10 minutes of the
1st unit, the client's lung sounds have audible crackles, VS: HR 128, RR 48
dyspnea, O2 sat 85%, and jugular vein distention is assessed. Which of these
interventions should be implemented as priority? Select all that apply.
a. Slow the infusion to run over 4 hours maximum.
b. Raise the HOB up 45 degrees and begin oxygen BNC at 2-4 L/M.
c. Discontinue all IV fluids infusing with the blood.
d. Notify the health care provider immediately.
e. Stop the infusion immediately. - ANSWER- a. Slow the infusion to run over 4
hours maximum.
b. Raise the HOB up 45 degrees and begin oxygen BNC at 2-4 L/M.
c. Discontinue all IV fluids infusing with the blood.
d. Notify the health care provider immediately.
Rationale:
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