Nokea
A patients low hemoglobin level has necessitated transfusion of PRBCs. Prior to administration, what action should the nurse perform?
- A. Have the patient identify his or her blood type in writing.
- B. Ensure that the patient has granted verbal consent for transfusion.
- C. Assess the patients vital signs to establish baselines.
- D. Facilitate insertion of a central venous catheter.
Correct Answer: C
Rationale: Prior to a transfusion, the nurse must take the patients temperature, pulse, respiration, and BP to establish a baseline. Written consent is required and the patients blood type is determined by type and cross match, not by the patients self-declaration. Peripheral venous access is sufficient for blood transfusion.
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A patient is receiving a blood transfusion and complains of a new onset of slight dyspnea. The nurses rapid assessment reveals bilateral lung crackles and elevated BP. What is the nurses most appropriate action?
- A. Slow the infusion rate and monitor the patient closely.
- B. Discontinue the transfusion and begin resuscitation.
- C. Pause the transfusion and administer a 250 mL bolus of normal saline.
- D. Discontinue the transfusion and administer a beta-blocker, as ordered.
Correct Answer: A
Rationale: The patient is showing early signs of hypervolemia; the nurse should slow the infusion rate and assess the patient closely for any signs of exacerbation. At this stage, discontinuing the transfusion is not necessary. A bolus would worsen the patients fluid overload.
Which of the following circumstances would most clearly warrant autologous blood donation?
- A. The patient has type-O blood.
- B. The patient has sickle cell disease or a thalassemia.
- C. The patient has elective surgery pending.
- D. The patient has hepatitis C.
Correct Answer: C
Rationale: Autologous blood donation is useful for many elective surgeries where the potential need for transfusion is high. Type-O blood, hepatitis, sickle cell disease, and thalassemia are not clear indications for autologous donation.
A clients health history reveals daily consumption of two to three bottles of wine. The nurse should plan assessments and interventions in light of the patients increased risk for what hematologic disorder?
- A. Leukemia
- B. Anemia
- C. Thrombocytopenia
- D. Lymphoma
Correct Answer: B
Rationale: Heavy alcohol use is associated with numerous health problems, including anemia. Leukemia and lymphoma are not associated with alcohol use; RBC levels are typically affected more than platelet levels.
A patient with a hematologic disorder asks the nurse how the body forms blood cells. The nurse should describe a process that takes place where?
- A. In the spleen
- B. In the kidneys
- C. In the bone marrow
- D. In the liver
Correct Answer: C
Rationale: Bone marrow is the primary site for hematopoiesis. The liver and spleen may be involved during embryonic development or when marrow is destroyed. The kidneys release erythropoietin, which stimulates the marrow to increase production of red blood cells (RBCs). However, blood cells are not primarily formed in the spleen, kidneys, or liver.
A patients electronic health record states that the patient receives regular transfusions of factor IX. The nurse would be justified in suspecting that this patient has what diagnosis?
- A. Leukemia
- B. Hemophilia
- C. Hypoproliferative anemia
- D. Hodgkins lymphoma
Correct Answer: B
Rationale: Administration of clotting factors is used to treat diseases where these factors are absent or insufficient; hemophilia is among the most common of these diseases. Factor IX is not used in the treatment of leukemia, lymphoma, or anemia.