Nokea
A patient is receiving the first of two ordered units of PRBCs. Shortly after the initiation of the transfusion, the patient complains of chills and experiences a sharp increase in temperature. What is the nurses priority action?
- A. Position the patient in high Fowlers.
- B. Discontinue the transfusion.
- C. Auscultate the patients lungs.
- D. Obtain a blood specimen from the patient.
Correct Answer: B
Rationale: Stopping the transfusion is the first step in any suspected transfusion reaction. This must precede other assessments and interventions, including repositioning, chest auscultation, and collecting specimens.
You may also like to solve these questions
A patient is scheduled for a splenectomy. During discharge education, what teaching point should the nurse prioritize?
- A. The importance of adhering to prescribed immunosuppressant therapy
- B. The need to report any signs or symptoms of infection promptly
- C. The need to ensure adequate folic acid, iron, and vitamin B12 intake
- D. The importance of limiting activity postoperatively to prevent hemorrhage
Correct Answer: B
Rationale: After splenectomy, the patient is instructed to seek prompt medical attention if even relatively minor symptoms of infection occur. Often, patients with high platelet counts have even higher counts after splenectomy, which can predispose them to serious thrombotic or hemorrhagic problems. However, this increase is usually transient and therefore often does not warrant additional treatment. Dietary modifications are not normally necessary and immunosuppressants would be strongly contraindicated.
An older adult client is exhibiting many of the characteristic signs and symptoms of iron deficiency. In addition to a complete blood count, what diagnostic assessment should the nurse anticipate?
- A. Stool for occult blood
- B. Bone marrow biopsy
- C. Lumbar puncture
- D. Urinalysis
Correct Answer: A
Rationale: Iron deficiency in the adult generally indicates blood loss (e.g., from bleeding in the GI tract or heavy menstrual flow). Bleeding in the GI tract can be preliminarily identified by testing stool for the presence of blood. A bone marrow biopsy would not be undertaken for the sole purpose of investigating an iron deficiency. Lumbar puncture and urinalysis would not be clinically relevant.
The nurse is providing care for an older adult who has a hematologic disorder. What age-related change in hematologic function should the nurse integrate into care planning?
- A. Bone marrow in older adults produces a smaller proportion of healthy, functional blood cells.
- B. Older adults are less able to increase blood cell production when demand suddenly increases.
- C. Stem cells in older adults eventually lose their ability to differentiate.
- D. The ratio of plasma to erythrocytes and lymphocytes increases with age.
Correct Answer: B
Rationale: Due to a variety of factors, when an older person needs more blood cells, the bone marrow may not be able to increase production of these cells adequately. Stem cell activity continues throughout the lifespan, although at a somewhat decreased rate. The proportion of functional cells does not greatly decrease and the relative volume of plasma does not change significantly.
The nurse is preparing to administer a unit of platelets to an adult patient. When administering this blood product, which of the following actions should the nurse perform?
- A. Administer the platelets as rapidly as the patient can tolerate.
- B. Establish IV access as soon as the platelets arrive from the blood bank.
- C. Ensure that the patient has a patent central venous catheter.
- D. Aspirate 10 to 15 mL of blood from the patients IV immediately following the transfusion.
Correct Answer: A
Rationale: The nurse should infuse each unit of platelets as fast as patient can tolerate to diminish platelet clumping during administration. IV access should be established prior to obtaining the platelets from the blood bank. A central line is appropriate for administration, but peripheral IV access (22-gauge or larger) is sufficient. There is no need to aspirate after the transfusion.
An interdisciplinary team has been commissioned to create policies and procedures aimed at preventing acute hemolytic transfusion reactions. What action has the greatest potential to reduce the risk of this transfusion reaction?
- A. Ensure that blood components are never infused at a rate greater than 125 mL/hr.
- B. Administer prophylactic antihistamines prior to all blood transfusions.
- C. Establish baseline vital signs for all patients receiving transfusions.
- D. Be vigilant in identifying the patient and the blood component.
Correct Answer: D
Rationale: The most common causes of acute hemolytic reaction are errors in blood component labeling and patient identification that result in the administration of an ABO-incompatible transfusion. Actions to address these causes are necessary in all health care settings. Prophylactic antihistamines are not normally administered, and would not prevent acute hemolytic reactions. Similarly, baseline vital signs and slow administration will not prevent this reaction.