170 unit 1

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 would ask which initial question?

• "Have you ever had a transfusion before?"

• "Why do you think that you need the transfusion?"

• "Have you ever gone into shock for any reason in the past?"

• "Do you know the complications and risks of a transfusion?"

A client with anemia who is receiving a transfusion of packed red blood cells (PRBCs) begins to vomit. The client's blood pressure is 90/50 mm Hg from a baseline of 125/78 mm Hg. The client's temperature is 100.8° F (38.2° C) orally from a baseline of 99.2° F (37.3° C) orally. The nurse determines that the client may be experiencing which complication of a blood transfusion?

• Septicemia

• Hyperkalemia

• Circulatory overload

• Delayed transfusion reaction

The nurse determines that a client is having a transfusion reaction. After the nurse stops the transfusion, which action would be taken next?

• Remove the intravenous (IV) line.

• Run a solution of 5% dextrose in water.

• Run normal saline at a keep-vein-open rate.

• Obtain a culture of the tip of the catheter device removed from the client.

A client has received a transfusion of platelets. The nurse evaluates that the client is benefiting most from this therapy if the client exhibits which finding?

• Increased hematocrit level

• Increased hemoglobin level

• Decline of elevated temperature to normal

• Decreased oozing of blood from puncture sites and gums

The nurse has obtained a unit of blood from the blood bank for administration to a client with anemia. The nurse has checked the blood bag properly with another nurse. Just before beginning the transfusion, the nurse would assess which priority item?

• Vital signs

• Skin color

• Urine output

• Latest hematocrit level

The nurse has just received a prescription to transfuse a unit of packed red blood cells for an assigned client. What action would the nurse take next?

• Check a set of vital signs.

• Order the blood from the blood bank.

• Obtain Y-site blood administration tubing.

• Check to be sure that consent for the transfusion has been signed.

Following infusion of a unit of packed red blood cells to treat anemia, the client has developed new onset of tachycardia, bounding pulses, crackles, and wheezes. Which action would the nurse implement first?

• Maintain bed rest with legs elevated.

• Place the client in high-Fowler's position.

• Increase the rate of infusion of intravenous fluids.

• Consult with the primary health care provider (PHCP) regarding initiation of oxygen therapy.

The nurse is caring for a client who is receiving a blood transfusion and is complaining of a cough. The nurse checks the client's vital signs, which include a temperature of 97.2° F (36.2° C), pulse of 108 beats per minute, blood pressure of 152/76 mm Hg, respiratory rate of 24 breaths per minute, and an oxygen saturation level of 95% on room air. The client denies pain at this time. Based on this information, what initial action would the nurse take?

• Collect a urine sample for analysis.

• Place the client in an upright position.

• Slow the rate of the blood transfusion.

• Compare current data to baseline data.

A client has experienced high blood pressure and crackles in the lungs during previous blood transfusions. The client asks the nurse whether it is safe to receive another transfusion. The nurse explains that which medication most likely will be prescribed before the transfusion is begun?

• Furosemide

• Acetaminophen

• Diphenhydramine

• Acetylsalicylic acid

The nurse has discontinued a unit of blood that was infusing into a client because the client experienced a transfusion reaction. After documenting the incident appropriately, the nurse sends the blood bag and tubing to which department?

• Blood bank

• Infection control

• Risk management

• Environmental services