Test bank for clinical nursing skills and techniques 7th edition by perry download

TOP: Blood Type KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 3.. DIF: Cognitive Level: Comprehension REF: Text Reference: Page 786 OBJ: Demonstrate the follo

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Techniques 7th Edition by Perry

Chapter 29: Blood Transfusions

MULTIPLE CHOICE

1 For how long may packed red blood cells (RBCs) be stored, if not frozen?

a 4 weeks

b Several years

c 72 hours

d 24 hours

ANS: A

A unit of RBCs can be stored for 4 weeks or, if frozen, for several years DIF: Cognitive Level: Knowledge REF: Text Reference: Page 786

OBJ: Discuss indications for blood therapy TOP: Packed Red Cells

KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

2 The patient has been tested and found to have blood type O This means that which antigen is present on the surface of the red blood cells?

a The type A antigen is present

b The type B antigen is present

c Neither type A nor type B antigens are present

d Both type A and type B antigens are present

ANS: C

When neither A nor B antigens are present, the blood group is type O

When the type A antigen is present, the blood group is called type A When the type B antigen is present, the blood group is type B When both A and B antigens are present, the blood group is type AB

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DIF: Cognitive Level: Comprehension REF: Text Reference: Page

786

OBJ: Describe various transfusion reactions TOP: Blood Type

KEY: Nursing Process Step: Assessment MSC: NCLEX:

Physiological Integrity

3 A nurse is concerned about the type of blood that a patient is to receive

Which type blood may a patient with an O blood type safely receive?

a Type A blood

b Type B blood

c Type AB blood

d Type O blood

ANS: D

People with type O blood have both A and B antibodies, and therefore can

receive only type O blood

People with type A blood have anti-B antibodies, therefore type A blood

People with type B blood have anti-A antibodies, therefore type B blood

People with type AB blood have neither antibody and therefore can receive

all blood types

DIF: Cognitive Level: Comprehension REF: Text Reference: Page 786

OBJ: Demonstrate the following skills on selected patients: initiating blood

therapy, implementing autotransfusion, and monitoring for adverse

reactions to transfusion

TOP: Type O Blood KEY:

Assessment

MSC: NCLEX: Physiological Integrity

Nursing Process Step:

4 The patient is brought to the emergency department following a motor vehicle

accident and has lost a large volume of blood The patient’s blood type is AB

Which blood type may this patient safely receive in transfusion?

a Can receive only type AB blood

b Can receive only type O blood

c Can receive all blood types

d Can receive only type A blood

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ANS: C

People with type AB blood have neither antibody and therefore can receive

all blood types

DIF: Cognitive Level: Comprehension REF: Text Reference: Page 786

therapy, implementing autotransfusion, and monitoring for adverse reactions

to transfusion

TOP: Type AB Blood KEY:

Assessment

5 The patient has received a total of 7 units of blood over the last 24 hours

The nurse assesses the patient’s laboratory test results in the morning

Which of the following would be an expected complication?

a Hypokalemia

b Hypercalcemia

c Hypocalcemia

d Iron deficiency

ANS: C

Blood that is preserved with citrate phosphate dextrose (CPD) contains a

high concentration of citrate ions The excess citrate may combine with the

ionized calcium in the recipient’s blood, resulting in transient low ionized

calcium levels Although ionized calcium deficiency resulting from blood

transfusions is rare, it is more likely to occur in young children, older

adults, and patients with osteoporosis

When blood is stored, there is continual destruction of RBCs, which releases

potassium from the cells into the plasma If blood is transfused rapidly,

transient hyperkalemia may occur before the potassium is reabsorbed Patients

receiving multiple transfusions should be assessed for iron overload

DIF: Cognitive Level: Application REF: Text Reference: Page 788

OBJ: Describe various transfusion reactions TOP:

Hypocalcemia

KEY: Nursing Process Step: Implementation

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29-4

6 The patient has received a total of 7 units of blood over the last 8 hours The

nurse assesses the patient’s laboratory test results Which of the following

would be an expected complication?

a Hypokalemia

b Hyperkalemia

c Hypercalcemia

d Iron deficiency

ANS: B

When blood is stored, there is continual destruction of RBCs, which releases

potassium from the cells into the plasma If blood is transfused rapidly,

transient hyperkalemia may occur before the potassium is reabsorbed

Blood that is preserved with citrate phosphate dextrose (CPD) contains a

high concentration of citrate ions The excess citrate may combine with the

ionized calcium in the recipient’s blood, resulting in transient low ionized

calcium levels Patients receiving multiple transfusions should be assessed

for iron overload

Hyperkalemia

KEY: Nursing Process Step: Implementation

7 The patient is to receive 2 units of packed RBC The units are cold, and the

nurse is concerned that this could lead to dysrhythmias and/or a reduction in

core temperature What action may the nurse take to prevent this?

a Warm the blood in a microwave

b Warm the blood using hot water

c Warm the blood using a blood warmer

d Allow the blood to warm to room temperature before administering

ANS: C

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In emergency situations, rapid transfusion of cold blood may lead to

dysrhythmias and a reduction in core temperature Sometimes a blood

warmer machine is used for large transfusions of greater than 50

mL/kg/hr or in patients with cold agglutinins

Heating blood products in a microwave or with hot water is dangerous

and may destroy blood cells Blood must be given within a prescribed

time frame Allowing the blood to come to room temperature before

administration would decrease the time available for administration

OBJ: Describe various transfusion reactions TOP: Blood Warmer

KEY:

MSC:

Nursing Process Step: Implementation NCLEX: Physiological Integrity

8 The patient is scheduled to receive 1 unit of packed RBCs She has

small, fragile veins, and a 22-gauge intravenous (IV) patent catheter is in

place What should the nurse do?

a Cancel the blood transfusion

b Insert a 16-gauge IV catheter into the antecubital fossa

c Use the IV catheter that is in place

d Transfuse the blood over 6 hours

ANS: C

In emergency situations that require rapid transfusions, a large-gauge

cannula is preferred; however, transfusions for therapeutic indications

may be infused with cannulas ranging from 20 to 24 gauge

Large-gauge cannulas (18 or 20 gauge) promote rapid flow of blood

components 16-gauge catheters frequently are used in surgery, but not

usually on acute care units Blood must be transfused within 4 hours Use

of smaller cannula gauges, such as 24 gauge, often requires the blood bank

to divide the unit so that each half can be infused within the allotted time or

to require pressure-assisted devices

OBJ: Describe various transfusion reactions TOP: IV Catheter Size

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KEY:

MSC:

Nursing Process Step: Implementation NCLEX: Physiological Integrity

9 What primary intervention should a nurse who is preparing a

blood transfusion perform?

a Set up the Y tubing

b Obtain 0.9% saline

c Verify the blood product and the patient

d Have the patient void or empty the urine drainage container

ANS: C

Correctly verify the product and identify the patient with a person

considered qualified by your agency Strict adherence to verification

procedures before administration of blood or blood components reduces

the risk for administering the wrong blood to the patient Clerical errors are

the cause of most hemolytic transfusion reactions

Y tubing is used to facilitate maintenance of IV access in case a patient will

need more than 1 unit of blood However, the focus here is on prevention of

possible blood reactions Use of Y tubing will not prevent a blood reaction

Normal saline is compatible with blood products, unlike solutions that

contain dextrose, which causes coagulation of donor blood However, strict

adherence to verification procedures before administration of blood or blood

components reduces the risk for administering the wrong blood to the

patient Empty urine drainage collection container or have patient void If a

transfusion reaction occurs, a urine specimen containing urine produced

after initiation of the transfusion will be sent to the laboratory

to transfusion

TOP: Pretransfusion Procedure KEY:

Implementation

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10 The patient is to receive 1 unit of packed RBCs The nurse obtains the

blood from the blood bank and returns to the unit to find that the patient has

been taken to radiology for a CT scan and is expected to return in about an

hour What should the nurse do?

a Go to radiology and administer the blood

b Keep the blood refrigerated until the patient returns

c Return the blood to the blood bank

d Hang the blood in the patient’s room and start it when the

patient returns

ANS: C

Initiate the blood transfusion within 30 minutes from time of release from

blood bank If you cannot do this because the patient is in the bathroom or

the physician has to be notified of an elevated temperature, immediately

return the blood to the blood bank, and retrieve it when you can

administer it

to transfusion

TOP: Delayed Start of Transfusion KEY:

Implementation

11 The nurse is preparing to administer a unit of blood to a patient using blood

tubing On the blood product side of the Y tubing, she will hang blood

What will she hang on the other side of the Y tubing?

a Dextrose 5%

b Normal saline

c Dextrose 10%

d Dextrose 5%/normal saline

ANS: B

Normal saline is compatible with blood products, unlike solutions

that contain dextrose, which causes coagulation of donor blood

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TOP: Normal Saline and Blood Products KEY: Nursing Process Step:

Implementation

MSC:

12 The nurse is administering blood What should the nurse do to detect a blood

reaction as quickly as possible?

a Remain with the patient during the first 15 minutes

b Transfuse the blood at 10 mL/min

c Monitor vital signs q 1 hour

d Transfuse blood at 50 gtt/min

ANS: A

Remain with patient during the first 15 minutes of a transfusion Most

transfusion reactions occur within the first 15 minutes of a transfusion

Initial flow rate during this time should be 2 mL/min, or 20 gtt/min Infusing

a small amount of blood component initially minimizes the volume of blood

to which the patient is exposed, thereby minimizing the severity of a

reaction Monitor patient’s vital signs at 5 minutes, 15 minutes, and every

30 minutes until 1 hour after transfusion or per agency policy Frequent

monitoring of vital signs will help to quickly alert the nurse to a transfusion

reaction

TOP: Early Detection of Blood Reaction KEY:

Implementation

13 An appropriate technique for the nurse to implement for a blood transfusion

is to:

a Provide medication through the IV line with the blood

b Regulate the flow of blood so that it infuses over 8 hours

c Clear the IV tubing with normal saline after the blood infuses

NCLEX: Physiological Integrity

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d Administer a blood product with clots through a filter line

ANS: C

After blood has infused, clear the IV line with 0.9% normal saline

and discard blood bag according to agency policy

Medication should never be injected into the same IV line as a blood

component because of the risk for contaminating the blood product with

pathogens and the possibility of incompatibility A separate IV line must be

maintained if the patient requires IV infusion (total parenteral nutrition, pain

control) during the transfusion A unit of blood should not hang for longer

than 4 hours because of the danger of bacterial growth Check appearance of

blood product for leaks, bubbles, clots, or purplish color Do not transfuse

blood if integrity is compromised Blood serves as a medium for bacteria

TOP: Blood Product Administration KEY:

Implementation

14 When a patient’s adverse reaction to a blood transfusion is

differentiated, which of the following signs/symptoms indicates the

presence of an anaphylactic response?

a Wheezing and chest pain

b Headache and muscle pain

c Hypotension and tingling of the extremities

d Crackles in the lungs and increased central venous pressure

ANS: A

Observe the patient for wheezing, chest pain, and possible cardiac arrest

All of these are indications of an anaphylactic reaction

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Be alert to patient complaints of headache or muscle pain in the presence

of a fever Both may be indicative of a febrile nonhemolytic reaction In

patients receiving massive transfusions, observe patient for mild

hypothermia, cardiac dysrhythmias, hypotension, and hypocalcemia Cold

blood products can affect the cardiac conduction system, resulting in

ventricular dysrhythmias Other cardiac dysrhythmias, hypotension, and

tingling may indicate hypocalcemia, which occurs when citrate (used as a

preservative for some blood products) combines with the patient’s calcium

Crackles in bases of lungs and a rising central venous pressure (CVP) are

indications of circulatory overload

DIF: Cognitive Level: Analysis REF: Text Reference: Page 797

Anaphylactic Response

KEY: Nursing Process Step: Evaluation MSC: NCLEX:

Physiological Integrity

15 The patient is receiving a unit of packed RBCs Fifteen minutes into the

procedure, he complains of severe kidney pain, and his temperature

increases 3 degrees Fahrenheit The nurse stops the transfusion

immediately, suspecting that which of the following reactions is occurring?

a A delayed hemolytic transfusion reaction

b A nonhemolytic febrile reaction

c An acute hemolytic transfusion reaction

d A severe allergic reaction

ANS: C

Symptoms of an acute hemolytic reaction usually begin within 15 minutes

of transfusion initiation and include severe pain in the kidney area and chest,

increased temperature (up to 105 F), increased heart rate, and sensation

of heat and pain along vein receiving blood, as well as chills, low back pain,

headache, nausea, chest or back pain, chest tightness, dyspnea,

bronchospasm, anxiety, hypotension, vascular collapse, disseminated

intravascular coagulation, and possibly death

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