a
26. The nurse's brief review of a client's electronic health record indicates that the client regularly undergoes therapeutic phlebotomy. Which of the following rationales for this procedure is most plausible?
A. The client may chronically produce excess red blood cells.
B. The client may frequently experience a low relative plasma volume.
C. The client may have impaired stem cell function.
D. The client may previously have undergone bone marrow biopsy.
ANS: A
Rationale: Persistently elevated hematocrit is an indication for therapeutic phlebotomy. It is not used to address excess or deficient plasma volume and is not related to stem cell function. Bone marrow biopsy is not an indication for therapeutic phlebotomy.
35. A client lives with a diagnosis of sickle cell disease and receives frequent blood transfusions. The nurse should recognize the client's consequent risk of what complication of treatment?
A. Hypovolemia
B. Vitamin B12 deficiency
C. Thrombocytopenia
D. Iron overload
ANS: D
Rationale: Clients with chronic transfusion requirements can quickly acquire more iron than they can use, leading to iron overload. These individuals are not at risk for hypovolemia and there is no consequent risk for low platelet or vitamin B12 levels.
36. A client is receiving the first of two prescribed units of PRBCs. Shortly after the initiation of the transfusion, the client reports chills and experiences a sharp increase in temperature. What is the nurse's priority action?
A. Position the client in high Fowler position
B. Discontinue the transfusion.
C. Auscultate the client's lungs.
D. Obtain a blood specimen from the client.
ANS: 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.
27. A nurse has participated in organizing a blood donation drive at a local community center. Which client would most likely be disallowed from donating blood?
A. A client who is 81 years of age
B. A client whose blood pressure is 78/49 mm Hg C. A client who donated blood 4 months ago
D. A client who has type 1 diabetes
ANS: B
Rationale: For potential blood donors, systolic arterial blood pressure should be 80 to 180 mm Hg, and the diastolic pressure should be 50 to 100 mm Hg. There is no absolute upper age limit. Donation 4 months ago does not preclude safe repeat donation (donors are only required to wait at least 8 weeks between donations), and diabetes is not a contraindication.
34. A client is receiving a blood transfusion and reports a new onset of slight dyspnea. The nurse's rapid assessment reveals bilateral lung crackles and elevated BP. What is the nurse's most appropriate action?
A. Slow the infusion rate and monitor the client 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 prescribed.
ANS: A
Rationale: The client is showing early signs of hypervolemia; the nurse should slow the infusion rate and assess the client closely for any signs of exacerbation. At this stage, discontinuing the transfusion is not necessary. A bolus would worsen the client's fluid overload.
37. Fresh-frozen plasma (FFP) has been prescribed for a hospital client. Prior to administration of this blood product, the nurse should prioritize which client education?
A. Infection risks associated with FFP administration
B. Physiologic functions of plasma
C. Signs and symptoms of a transfusion reaction
D. Strategies for managing transfusion-associated anxiety
ANS: C
Rationale: Clients should be educated about signs and symptoms of transfusion reactions prior to administration of any blood product. In most cases, this is priority over education relating to infection. Anxiety may be an issue for some clients, but transfusion reactions are life-threatening and should be addressed first. Teaching about the functions of plasma is not likely a high priority.
28. A nurse at a blood donation clinic has completed the collection of blood from a client. The client reports feeling "light-headed" and appears pale. Which action by the nurse is most appropriate?
A. Help the client to sit, with head lowered below knees.
B. Administer supplementary oxygen by nasal prongs.
C. Obtain a full set of vital signs.
D. Inform a health care provider or other primary care provider.
ANS: A
Rationale: A donor who appears pale or complains of faintness should immediately lie down or sit with the head lowered below the knees. The client should be observed for another 30 minutes. There is no immediate need for a health care provider's care. Supplementary oxygen may be beneficial, but may take too much time to facilitate before a syncopal episode. Repositioning must precede assessment of vital signs.
33. 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/h.
B. Administer prophylactic antihistamines prior to all blood transfusions.
C. Establish baseline vital signs for all clients receiving transfusions.
D. Be vigilant in identifying the client and the blood component.
ANS: D
Rationale: The most common causes of acute hemolytic reaction are errors in blood component labeling and client 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 given, and would not prevent acute hemolytic reactions. Similarly, baseline vital signs and slow administration will not prevent this reaction.
38. The nurse is preparing to administer a unit of platelets to an adult client. When administering this blood product, which of the following actions should the nurse perform?
A. Administer the platelets as rapidly as the client can tolerate.
B. Establish IV access as soon as the platelets arrive from the blood bank.
C. Ensure that the client has a patent central venous catheter.
D. Aspirate 10 to 15 mL of blood from the client's IV immediately following the transfusion.
ANS: A
Rationale: The nurse should infuse each unit of platelets as fast as client 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.
29. A client's low hemoglobin level has necessitated transfusion of packed red blood cells. Prior to administration, which action should the nurse perform?
A. Have the client identify the blood type in writing.
B. Ensure that the client has granted verbal consent for transfusion.
C. Assess the client's vital signs to establish baselines.
D. Facilitate insertion of a central venous catheter.
ANS: C
Rationale: Prior to a transfusion, the nurse must take the client's temperature, pulse, respiration, and blood pressure to establish a baseline. Written consent is required, and
the client's blood type is determined by type and cross match, not by the client's self-declaration. Peripheral venous access is sufficient for blood transfusion.
32. A client is being treated in the ICU after a medical error resulted in an acute hemolytic transfusion reaction. What was the etiology of this client's adverse reaction?
A. Antibodies to donor leukocytes remained in the blood.
B. The donor blood was incompatible with that of the client.
C. The client had a sensitivity reaction to a plasma protein in the blood.
D. The blood was infused too quickly and overwhelmed the client's circulatory system.
ANS: B
Rationale: An acute hemolytic reaction occurs when the donor blood is incompatible with that of the recipient. In the case of a febrile nonhemolytic reaction, antibodies to donor leukocytes remain in the unit of blood or blood component. An allergic reaction is a sensitivity reaction to a plasma protein within the blood component. Hypervolemia does not cause an acute hemolytic reaction.
39. Which of the following circumstances would most clearly warrant autologous blood donation?
A. The client has type-O blood.
B. The client has sickle cell disease or a thalassemia.
C. The client has elective surgery pending.
D. The client has hepatitis C.
ANS: 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.
30. A client on the medical unit is receiving a unit of packed red blood cells (PRBCs). Difficult intravenous (IV) access has necessitated a slow infusion rate, and the nurse notes that the infusion began 4 hours ago. Which action by the nurse is the most appropriate?
A. Apply an icepack to the blood that remains to be infused.
B. Discontinue the remainder of the PRBC transfusion, and inform the health care provider.
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.
ANS: B
Rationale: Because of the risk of increased bacterial proliferation in the PRBCs and subsequent infection in the client, 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.
31. Two units of packed red blood cells have been prescribed for a client who has experienced a gastrointestinal bleed. The client is highly reluctant to receive a transfusion, stating, "I'm terrified of getting acquired immunodeficiency syndrome (AIDS) from a blood transfusion." How can the nurse best address the client's concerns?
A. "All donated blood is treated with antiretroviral medications before it is used."
B. "That did happen in some high-profile cases in the 20th century, but it is no longer a possibility."
C. "HIV was eradicated from the blood supply in the early 2000s."
D. "Donated blood is screened for human immunodeficiency virus (HIV), and the risk of contraction is very low."
ANS: D
Rationale: The client can be reassured about the very low possibility of contracting HIV from the transfusion. However, it is not an absolute impossibility. Antiretroviral medications are not introduced into donated blood. The blood supply is constantly dynamic, due to the brief life of donated blood.
40. A client is scheduled to undergo a bone marrow aspiration. When preparing the client for the procedure, which action would the nurse do first?
A. Ensure informed consent has been obtained. B. Cleanse the skin with an antiseptic.
C. Administer a local anesthetic.
D. Cover the area with a sterile drape.
ANS: A
Rationale: The first step in the procedure is ensuring that informed consent has been obtained by the health care provider, nurse practitioner, or health care provider assistant performing the procedure and includes the reason the procedure is being performed, alternatives, and risks of the procedure. Risks include infection, bleeding, and pain. After informed consent is obtained, the client is assisted to either a prone or lateral decubitus position. The skin is cleansed using aseptic technique and either a chlorhexidine-based solution or povidone-iodine. A sterile drape is applied, and the skin is numbed using local anesthesia.