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Blood Transfusions AH 2 Test 3

Number of questions: 11

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1) The client receiving a unit of packed red blood cells begins to chill and develop hives. Which action should be the nurse's first response?
  1. Administer the histamine-1 blocker, benadryl, IV
  2. Assess the client for further complications
  3. Notify the laboratory and HCP
  4. Stop the transfusion and change the tubing at the hub
 2) The HCP orders two units of blood to be administered over eight hours each for a client diagnosed with heart failure. Which intervention(s) should the nurse take?
  1. Call the HCP to question the order because blood must infuse within four hours
  2. Infuse each unit for four hours, the maximum rate for a unit of blood
  3. Notify the lab to split each unit into half units and infuse each half for four hours
  4. Retrieve the blood from the laboratory and run each unit at an eight hour rate
 3) The nurse and an unlicensed assistive personnel (UAP) are caring for clients on an oncology floor. Which nurse task would be delegated to the UAP?
  1. Assess the urine output on a client who has had a blood transfusion reaction
  2. Assist the client who received 10 units of platelets in brushing their teeth
  3. Auscultate the lung sounds of a client before a transfusion
  4. Take the first 15 min. of vital signs on a client receiving a unit of packed RBCs
 4) The client has a hematocrit of 22.3% and a hemoglobin of 7.7 g/dL. The HCP has ordered two units of packed RBC's to be transfused. Which interventions should the nurse implement? (Select all that apply)
  1. Obtain a signed consent
  2. Initiate a 22G IV
  3. Assess the client's lungs
  4. Check for allergies
 5) The client undergoing knee replacement surgery has a "cell saver" apparatus attached to the knee when he arrives in the post anesthesia care unit (PACU). Which intervention should the nurse implement to care for this drainage system?
  1. Attach an hourly drainage collection bag to the unit and discard the drainage
  2. Have another nurse verify the unit number before reinfusing the blood
  3. Infuse the drainage into the client when a prescribed amount fills the chamber
  4. Replace the unit with a continuous passive motion unit and start it on low
 6) The nurse is caring for clients on a medical floor. After the shift report, which client should be assessed first?
  1. The client diagnosed with Crohn's disease who is complaining of perineal discomfort
  2. The client diagnosed with leukemia who has a hematocrit of 18% and petechiae covering the body
  3. The client who has two thirds of the through a blood transfusion and has had no complaints of dyspnea or hives
  4. The client with peptic ulcer disease who called over the intercom to say that he is vomiting blood
 7) The client is scheduled to have a total hip replacement in two months and has chosen to prepare for autologous transfusion. Which medications would the nurse administer to prepare the client?
  1. Ativan, a tranquilizer
  2. Epogen, a biologic response modifier
  3. Prednisone, a glucocorticoid
  4. Zithromax, an antibiotic
 8) The client is admitted to the emergency department after a motor vehicle accident. The nurse notes profuse bleeding from a right sided injury. Which intervention should the nurse implement first?
  1. Have the client sign a consent for an exploratory laparotomy
  2. Initiate an IV with an 18G needle and hang normal saline
  3. Notify the S/O of the client's admission
  4. Type & crossmatch for RBCs immediately (STAT)
 9) An O+ patient needs a blood transfusion but no O+ blood is available. Which type can be given instead?
  1. AB+
  2. AB−
  3. B+
  4. O−
 10) Why is donated blood kept refrigerated?
  1. To increase its oxygen-carrying capacity
  2. To prevent coagulation
  3. To prevent the blood from producing alloantibodies
  4. To slow bacterial growth
 11) Which of these people should NOT donate blood?
  1. A breastfeeding mother with a six-week-old newborn
  2. Someone who had wisdom teeth removed a week ago
  3. Someone who received a measles immunization two months ago
  4. Someone with an aspirin allergy

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