26. Confirm the transfusion has been prescribed
Verify your patient and witness consent
Confirm type and cross match
Have two nurses approve the patient and
blood product
◦ Date, initial, and complete verification form
◦ Attach to the blood until transfusion is complete.
Obtain and record vitals immediately prior to
administration
Be sure to assess patients reaction
27. Monitor patient closely for 15 minutes, if no
reactions occur increase flow rate
At completion record: date and time, total
volume, and if any reactions occurred, and
last vitals taken
28.
29. A male patient with blood type AB, Rh factor
positive needs a blood transfusion. The
Transfusion Service (blood bank) sends type
O, Rh factor negative blood to the unit for the
nurse to infuse into this patient. The nurse
knows that:
30. a. This donor blood is incompatible with the
patient’s blood.
b. Premedicating the patient with
diphenhydramine hydrochloride (Benadryl)
and acetaminophen (Tylenol) will prevent any
transfusion reactions or side effects.
c. This is a compatible match.
d. The patient is at minimal risk receiving this
product since it is the first time he has been
transfused with type O, Rh negative blood.
31. Answer C.
Type O, Rh negative blood has none of the
major antigens and is safely administered to
patients of all blood types. It is also known
as the universal donor. Premedicating with
these agents will not prevent a major
transfusion reaction if the blood type and Rh
factors of the donor blood are incompatible
with the recipient’s blood.
32. Dr. Rodriguez orders 250 milliliters of packed
red blood cells (RBC) for a patient. This
therapy is administered for treatment of:
a. Thrombocytopenia.
b. Anemia.
c. Leukopenia.
d. Hypoalbuminemia.
33. Answer B.
A red blood cell transfusion is used to correct
anemia in patients in which the low red blood
cell count must be rapidly corrected. RBC
transfusion will not correct a low platelet
count. RBC transfusion will not correct a low
white blood cell count. Packed RBCs contain
very little plasma and, thus, only a small
amount of albumin. This amount will not
correct low albumin levels.
34. A male patient needs to receive a unit of whole
blood. What type of intravenous (IV) device
should the nurse consider starting?
a. A small catheter to decrease patient
discomfort
b. The type of IV device the patient has had
in the past, which worked well
c. A large bore catheter
d. The type of device the physician prefers
35. Answer C.
Large bore catheters prevent damage to
blood components and are less likely to
develop clotting problems than a small bore
catheter. The nurse should determine the
correct device without asking the patient
what type has been used before or asking the
physician which type he prefers and start the
IV
36. Rho gam is most often used to treat____
mothers that have a ____ infant.
A: RH positive, RH positive
B: RH positive, RH negative
C: RH negative, RH positive
D: RH negative, RH negative
37. Answer C.
Rho gam prevents the production of anti-RH
antibodies in the mother that has a Rh positive
fetus.
38. A physician tells a client that the client needs a
blood transfusion and that a blood sample
must be drawn first for blood typing and
cross matching. After the physician leaves the
client asks the nurse, “What exactly is a blood
type?” The nurse responds with the following
statement.
39. A. “The blood type represent an antigen found
the surface of a RBC.”
B. “The blood type represent an antibody
found on the surface of the RBC.”
C. “The blood type represents an antigen that
normally circulates in the blood plasma.”
D. “The blood type represent an antibody that
normally circulates in the blood plasma.”
40. Answer A.
The major blood type are A, B, AB, and O. The
blood type indicates an antigen found on the
surface of the RBC. Acute hemolytic
transfusions reaction (ABO incapability) can
occur if a client receives blood that is not
compatible with his/her blood type. Acute
Hemolytic reaction is the most serious
adverse reaction to blood transfusion.
41. A hospitalized patient has received
transfusions of 2 units of blood
over the past few hours. A nurse
enters the room to find the patient
sitting up in bed, dyspneic and
uncomfortable.
42. On assessment, crackles are heard in the
bases of both lungs, probably indicating
that the patient is experiencing a
complication of transfusion. Which of the
following complications is most likely the
cause of the patient's symptoms?
43. A. Febrile non-hemolytic reaction.
B. Allergic transfusion reaction.
C. Acute hemolytic reaction.
D. Fluid overload.
44. Answer: D
Fluid overload occurs when then the fluid
volume infused over a short period is too
great for the vascular system, causing fluid
leak into the lungs. Symptoms include
dyspnea, rapid respirations, and discomfort as
in the patient described. Febrile non-
hemolytic reaction results in fever. Symptoms
of allergic transfusion reaction would include
flushing, itching, and a generalized rash.
Acute hemolytic reaction may occur when a
patient receives blood that is incompatible
with his blood type. It is the most serious
adverse transfusion reaction and can cause
shock and death.
45. A leukemia patient has a relative who wants
to donate blood for transfusion. Which of the
following donor medical conditions would
prevent this?
A. A history of hepatitis C five years
previously.
B. Cholecystitis requiring cholecystectomy
one year previously.
C. Asymptomatic diverticulosis.
D. Crohn's disease in remission.
46. Answer: A
Hepatitis C is a viral infection transmitted
through bodily fluids, such as blood, causing
inflammation of the liver. Patients with
hepatitis C may not donate blood for
transfusion due to the high risk of infection
in the recipient. Cholecystitis (gall bladder
disease), diverticulosis, and history of Crohn's
disease do not preclude blood donation.
47. A hospitalized patient is receiving packed
red blood cells (PRBCs) for treatment of
severe anemia. Which of the following is the
most accurate statement?
48. A. Transfusion reaction is most likely
immediately after the infusion is completed.
B. PRBCs are best infused slowly through a
20g. IV catheter.
C. PRBCs should be flushed with a 5%
dextrose solution.
D. A nurse should remain in the room during
the first 15 minutes of infusion.
49. Answer: D
Transfusion reaction is most likely during the
first 15 minutes of infusion, and a nurse
should be present during this period. PRBCs
should be infused through a 19g or larger IV
catheter to avoid slow flow, which can cause
clotting. PRBCs must be flushed with 0.45%
normal saline solution. Other intravenous
solutions will hemolyze the cells.
50. A female patient needs a whole blood
transfusion. In order for transfusion services
(the blood bank) to prepare the correct
product a sample of the patient’s blood must
be obtained for:
a. A complete blood count and differential.
b. A blood type and cross-match.
c. A blood culture and sensitivity.
d. A blood type and antibody screen.
51. Answer B.
This is needed to utilize the correct type of
donor blood and to match the donor product
with the patient. Incompatible matches would
result in severe adverse events and possible
death. The tests in options 1 and 3 are
unnecessary. The test in option 4 is utilized
to determine the patient’s blood type and
presence of antibodies to blood antigens. It
does not determine donor blood
compatibility with the patient.
52.
53. ATI Skills Module: Blood Administration
www.ati.com
http://www.studyguidezone.com/nclexrn_p
ractice3.htm
Saunders Edition 4 Comprehensive Review.
Nclex- RN Examination.
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www.nclexreviewers.com
mynursinglab.com
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