Exam (elaborations)

NUR 211 Blood Transfusion NCLEX |850 Questions |with Correct Answers and Rationale |

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Nursing

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Nursing

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...

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nur 211 blood transfusion nclex 850 questions wi

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NUR 211 Blood Transfusion NCLEX |850 Questions |
with Correct Answers and Rationale |
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. Correct Answer-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?" Correct
Answer-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?

1) Septicemia
2) Hyperkalemia
3) Circulatory overload
4) Delayed transfusion reaction Correct Answer-1) Septicemia

,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.

Circulatory overload causes cough, dyspnea, chest pain, wheezing,
tachycardia, and hypertension.

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. Correct Answer-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 Correct Answer-3) An in-line filter

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