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The nurse is planning the care of a patient with a nutritional deficit and a diagnosis of megaloblastic anemia. The nurse should recognize that this patients health problem is due to what?
- A. Production of inadequate quantities of RBCs
- B. Premature release of immature RBCs
- C. Injury to the RBCs in circulation
- D. Abnormalities in the structure and function RBCs
Correct Answer: D
Rationale: Vitamin B12 and folic acid deficiencies are characterized by the production of abnormally large erythrocytes called megaloblasts. Because these cells are abnormal, many are sequestered (trapped) while still in the bone marrow, and their rate of release is decreased. Some of these cells actually die in the marrow before they can be released into the circulation. This results in megaloblastic anemia. This pathologic process does not involve inadequate production, premature release, or injury to existing RBCs.
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An individual has accidentally cut his hand, immediately initiating the process of hemostasis. Following vasoconstriction, what event in the process of hemostasis will take place?
- A. Fibrin will be activated at the bleeding site.
- B. Platelets will aggregate at the injury site.
- C. Thromboplastin will form a clot.
- D. Prothrombin will be converted to thrombin.
Correct Answer: B
Rationale: Following vasoconstriction, circulating platelets aggregate at the site and adhere to the vessel and to one another, forming an unstable hemostatic plug. Events involved in the clotting cascade take place subsequent to this initial platelet action.
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.
A patient undergoing a hip replacement has autologous blood on standby if a transfusion is needed. What is the primary advantage of autologous transfusions?
- A. Safe transfusion for patients with a history of transfusion reactions
- B. Prevention of viral infections from another persons blood
- C. Avoidance of complications in patients with alloantibodies
- D. Prevention of alloimmunization
Correct Answer: B
Rationale: The primary advantage of autologous transfusions is the prevention of viral infections from another persons blood. Other secondary advantages include safe transfusion for patients with a history of transfusion reactions, prevention of alloimmunization, and avoidance of complications in patients with alloantibodies.
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.
A patient on the medical unit is receiving a unit of PRBCs. Difficult IV access has necessitated a slow infusion rate and the nurse notes that the infusion began 4 hours ago. What is the nurses most appropriate action?
- A. Apply an icepack to the blood that remains to be infused.
- B. Discontinue the remainder of the PRBC transfusion and inform the physician.
- C. Disconnect the bag of PRBCs, cool for 30 minutes and then administer.
- D. Administer the remaining PRBCs by the IV direct (IV push) route.
Correct Answer: B
Rationale: Because of the risk of infection, a PRBC transfusion should not exceed 4 hours. Remaining blood should not be transfused, even if it is cooled. Blood is not administered by the IV direct route.