A nurse is preparing to administer packed RBC to a client who has a hgb of 8 g/dl.
Which of the following actions should the nurse plan to take during
... [Show More] the first 15 min of
the transfusion?
a. Obtain consent from the client for the transfusion
b. Assess for an acute hemolytic reaction
c. Explain the transfusion procedure to the client
d. Obtain blood culture specimens to send to the lab - b
A nurse is caring for a client who is receiving a blood transfusion. Which of the
following actions should the nurse expect if an allergic transfusion reaction is
suspected? (select all that apply)
a. Stop the transfusion
b. Monitor for hypertension
c. Maintain an IV infusion with 0.9% sodium chloride
d. Position the client in an upright position with the feet lower than the heart
e. Administer diphenhydramine - ace
A nurse is monitoring a client who began receiving a unit of packed RBCs 10 min
ago. which of the following findings should the nurse identify as an indication of a
febrile transfusion reaction? (select all that apply)
a. Temperature change from 98.6 to 99
b. Current blood pressure 178/90
c. Heart rate change from 88/min pretransfusion to 120/min
d. Client report of itching
e. Client appears flushed - ce
A nurse is providing preoperative teaching for a client who requests autologous
donation in prparation for scheduled orthopedic surgical procedure. Which of the
following statements should the nurse include in the teaching
a. You should make an appointment to donate blood 8 weeks prior to the surgery
b. If you need an autologous transfusion, the blood your brother donates can be
used
c. You can donate blood each week if your hemoglobin is stable
d. Any unused blood that is donated can be used for other clients - c
A nurse preceptor is observing a newly licensed nurse on the unit who is preparing
to administer a blood transfusion to an older adult client. Which of the following
actions by the newly licensed nurse indicates an understanding of the procedure
a. Inserts an 18 g IV catheter in the client
b. Verifies blood compatibility and expiration date of the blood with an UAP
c. Administers dextrose in NS IV with the transfusion
d. Obtains vital signs every 15 min throughout the procedure - d
A client who is anticipating total hip replacement is considering autologous
transfusion. When teaching this client about autologous transfusion, it is important to
emphasize that?
a. It reduces the risk of mismatched blood
b. A hemoglobin level above 9.5 mg/dL is required
c. there is no need to test the blood for infectious diseases
d. Donations may be made every other day - a
A type of protein the immune system produces to neutralize a threat of some kind,
such as an incompatible substance in the blood, is called an?
a. Antigen
b. Allergen
c. Antibody
d. Agglutinogen - c
A platelet tranfusion is indicated for a client who?
a. Has a systemic infection
b. Has a thrombocytopenia
c. In is hypovolemic shock
d. Has hemolytic anemia - b
Prior to administering a blood transfusion, it is essential to explain to the client that
a. You will check his vital signs every 15 minutes throughout the blood transfusion
b. You might have a nursing assistant check on him periodically during the
transfusion
c. He must immediately report any subjective symptoms like chills, nausea, or itching
d. If he has no reaction in the first 15-30 minutes, he will not have any adverse
effects later - c [Show Less]