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Chapter 30: Blood Therapy
Perry et al.: Clinical Nursing Skills & Techniques, 9th Edition
MULTIPLE CHOICE
1. For how long may blood preserved with citrate-phosphate-dextrose (CPD) be stored
(unfrozen) before use?
21 days
35 days
42 days
3 months
a.
b.
c.
d.
ANS: A
When preserved with citrate, phosphate, and dextrose, a unit of blood has a shelf life of 21
days (unfrozen).
DIF: Cognitive Level: Knowledge
REF: Text reference: p. 801
OBJ: Discuss indications for blood therapy.
TOP: Packed Red Cells
KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
2. The nurse is caring for a patient who needs a blood transfusion. The patient has been tested
and was found to have blood type O. The nurse knows this means that which antigen is
present on the surface of the red blood cells?
a. The type A antigen is present.
b. The type B antigen is present.
c. Neither type A nor type B antigens are present.
d. Both type A and type B antigens are present.
ANS: C
When neither A nor B antigens are present, the blood group is type O. When the type A
antigen is present, the blood group is type A. When the type B antigen is present, the blood
group is type B. When both A and B antigens are present, the blood group is type AB.
DIF: Cognitive Level: Application
REF: Text reference: p. 801
OBJ: Describe various transfusion reactions.
TOP: Blood Type
KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
3. A nurse is concerned about the type of blood that a patient is to receive. A patient with an O
blood type may safely receive which type of blood?
Type A blood
Type B blood
Type AB blood
Type O blood
a.
b.
c.
d.
ANS: D
People with type O blood have both A and B antibodies and therefore can receive only type O
blood. People with type A blood have anti-B antibodies and therefore can receive only type A
blood. People with type B blood have anti-A antibodies and therefore can receive only type B
blood. People with type AB blood have neither antibodies and therefore can receive all blood
types.
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DIF: Cognitive Level: Comprehension
REF: Text reference: p. 801-802
OBJ: Demonstrate the following skills on selected patients: initiating blood therapy, implementing
autotransfusion, and monitoring for adverse reactions to transfusion.
TOP: Type O Blood
KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
4. The patient is brought to the emergency department after a motor vehicle accident and has lost
a large volume of blood. The patient’s blood type is AB. Which blood type may this patient
safely receive in transfusion?
a. Only type AB blood
b. Only type O blood
c. All blood types
d. Only type A blood
ANS: C
People with type AB blood have neither antibodies and therefore can receive all blood types.
DIF: Cognitive Level: Application
REF: Text reference: p. 802
OBJ: Demonstrate the following skills on selected patients: initiating blood therapy, implementing
autotransfusion, and monitoring for adverse reactions to transfusion.
TOP: Type AB Blood
KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
5. The patient is scheduled to receive a blood transfusion. Preadministration laboratory tests are
run to assess the level of which component in the patient’s blood?
Sodium (Na)
Calcium (Ca)
Potassium (K)
Iron (Fe)
a.
b.
c.
d.
ANS: C
When blood is stored, there is continual destruction of red blood cells (RBCs), which releases
potassium from the cells into the plasma. If blood is transfused rapidly, transient elevated
potassium levels may occur before the potassium is reabsorbed and put the patient at risk.
DIF: Cognitive Level: Application
REF: Text reference: p. 800|Text reference: p. 807
OBJ: Describe various transfusion reactions.
TOP: Hypocalcemia
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
6. The patient has received a total of 7 units of blood over the past 8 hours. The nurse assesses
the patient’s laboratory test results. Which of the following would be an expected
complication?
a. Hypokalemia
b. Hyperkalemia
c. Hypercalcemia
d. Iron deficiency
ANS: B
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When blood is stored, there is continual destruction of red blood cells (RBCs), which releases
potassium from the cells into the plasma. If blood is transfused rapidly, transient hyperkalemia
may occur before the potassium is reabsorbed. Blood that is preserved with citrate phosphate
dextrose (CPD) contains a high concentration of citrate ions. The excess citrate may combine
with the ionized calcium in the recipient’s blood, resulting in transient low ionized calcium
levels. Patients receiving multiple transfusions should be assessed for iron overload.
DIF: Cognitive Level: Application
REF: Text reference: p. 800|Text reference: p. 807
OBJ: Describe various transfusion reactions.
TOP: Hyperkalemia
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
7. The patient is to receive 2 units of packed red blood cells (RBCs). The units are cold, and the
nurse is concerned that this could lead to dysrhythmias and/or a reduction in core temperature.
What action may the nurse take to prevent this?
a. Warm the blood in a microwave.
b. Warm the blood using hot water.
c. Warm the blood using a blood warmer.
d. Allow the blood to warm to room temperature before administering.
ANS: C
In emergency situations, rapid transfusion of cold blood may lead to dysrhythmias and a
reduction in core temperature. Sometimes a blood warmer machine is used for large
transfusions of greater than 50 mL/kg/hr or in patients with cold agglutinins. Heating blood
products in a microwave or with hot water is dangerous and may destroy blood cells. Blood
must be given within a prescribed time frame. Allowing the blood to come to room
temperature before administration would decrease the time available for administration.
DIF:
OBJ:
KEY:
MSC:
Cognitive Level: Application
REF: Text reference: p. 806
Describe various transfusion reactions.
TOP: Blood Warmer
Nursing Process Step: Implementation
NCLEX: Physiological Integrity
8. The patient is scheduled to receive 1 unit of packed red blood cells (RBCs). She has small,
fragile veins, and a 22-gauge intravenous (IV) patent catheter is in place. What should the
nurse do?
a. Cancel the blood transfusion.
b. Insert a 16-gauge IV catheter into the antecubital fossa.
c. Use the IV catheter that is in place.
d. Transfuse the blood over 6 hours.
ANS: C
In emergency situations that require rapid transfusions, a large-gauge cannula is preferred;
however, transfusions for therapeutic indications may be infused with cannulas ranging from
20 to 24 gauge. Large-gauge cannulas (18 or 20 gauge) promote rapid flow of blood
components. 16-Gauge catheters are used frequently in surgery, but not usually on acute care
units. Blood must be transfused within 4 hours. Use of smaller-gauge cannulas, such as 24
gauge, often requires the blood bank to divide the unit so that each half can be infused within
the allotted time or requires the use of pressure-assisted devices.
DIF: Cognitive Level: Application
REF: Text reference: p. 813
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OBJ: Describe various transfusion reactions.
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
TOP: IV Catheter Size
9. What primary intervention should a nurse who is preparing a blood transfusion perform?
a. Set up the Y tubing.
b. Obtain 0.9% saline.
c. Verify the blood product and the patient.
d. Have the patient void or empty the urine drainage container.
ANS: C
Correctly verify the product and identify the patient with a person considered qualified by
your agency. Strict adherence to verification procedures before administration of blood or
blood components reduces the risk of administering the wrong blood to the patient. Clerical
errors are the cause of most hemolytic transfusion reactions. Y tubing is used to facilitate
maintenance of intravenous (IV) access in case a patient will need more than 1 unit of blood.
However, the focus here is on prevention of possible blood reactions. Use of Y tubing will not
prevent a blood reaction. Normal saline is compatible with blood products, unlike solutions
that contain dextrose, which causes coagulation of donor blood. However, strict adherence to
verification procedures before administration of blood or blood components reduces the risk
of administering the wrong blood to the patient. Empty the urine drainage collection container
or have the patient void. If a transfusion reaction occurs, a urine specimen containing urine
produced after initiation of the transfusion will be sent to the laboratory.
DIF: Cognitive Level: Application
REF: Text reference: p. 803
OBJ: Demonstrate the following skills on selected patients: initiating blood therapy, implementing
autotransfusion, and monitoring for adverse reactions to transfusion.
TOP: Pretransfusion Procedure
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
10. The patient is to receive 1 unit of packed red blood cells (RBCs). The nurse obtains the blood
from the blood bank and returns to the unit to find that the patient has been taken to radiology
for a computed tomography (CT) scan and is expected to return in about an hour. What should
the nurse do?
a. Go to radiology and administer the blood.
b. Keep the blood refrigerated until the patient returns.
c. Return the blood to the blood bank.
d. Hang the blood in the patient’s room and start it when the patient returns.
ANS: C
Initiate the blood transfusion within 30 minutes of the time of release from the blood bank. If
the blood cannot be started because the patient is in the bathroom or the physician has to be
notified of an elevated temperature, immediately return the blood to the blood bank, and
retrieve it when it can be administered.
DIF: Cognitive Level: Application
REF: Text reference: p. 809-810
OBJ: Demonstrate the following skills on selected patients: initiating blood therapy, implementing
autotransfusion, and monitoring for adverse reactions to transfusion.
TOP: Delayed Start of Transfusion
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
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11. The nurse is preparing to administer a unit of blood to a patient using blood tubing. On the
blood product side of the Y tubing, the nurse will hang blood. What will be hung on the other
side of the Y tubing?
a. Dextrose 5%
b. Normal saline
c. Dextrose 10%
d. Dextrose 5%/normal saline
ANS: B
Normal saline is compatible with blood products, unlike solutions that contain dextrose,
which causes coagulation of donor blood.
DIF: Cognitive Level: Application
REF: Text reference: p. 807
OBJ: Demonstrate the following skills on selected patients: initiating blood therapy, implementing
autotransfusion, and monitoring for adverse reactions to transfusion.
TOP: Normal Saline and Blood Products KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
12. The nurse is administering blood. What should the nurse do to detect a blood reaction as
quickly as possible?
Remain with the patient during the first 15 minutes.
Transfuse the blood at 10 mL/min.
Monitor vital signs q 1 hour.
Transfuse blood at 50 gtt/min.
a.
b.
c.
d.
ANS: A
Remain with the patient during the first 15 minutes of a transfusion. Most transfusion
reactions occur within the first 15 minutes of a transfusion. The initial flow rate during this
time should be 2 mL/min, or 20 gtt/min. Initially infusing a small amount of blood component
minimizes the volume of blood to which the patient is exposed, thereby minimizing the
severity of a reaction. Monitor the patient’s vital signs at 5 minutes, at 15 minutes, and every
30 minutes until 1 hour after transfusion or per agency policy. Frequent monitoring of vital
signs will help to quickly alert the nurse to a transfusion reaction.
DIF: Cognitive Level: Application
REF: Text reference: p. 811
OBJ: Demonstrate the following skills on selected patients: initiating blood therapy, implementing
autotransfusion, and monitoring for adverse reactions to transfusion.
TOP: Early Detection of Blood Reaction KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
13. An appropriate technique for the nurse to implement for a blood transfusion is to:
a. provide medication through the intravenous (IV) tubing with the blood.
b. regulate the flow of blood so that it infuses over 8 hours.
c. clear the IV tubing with normal saline after the blood infuses.
d. administer a blood product with clots through a filter line.
ANS: C
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After the blood has infused, clear the IV line with 0.9% normal saline and discard the blood
bag according to agency policy. Medication should never be injected into the same IV line as a
blood component because of the risk of contaminating the blood product with pathogens and
the possibility of incompatibility. A separate IV line must be maintained if the patient requires
IV infusion (total parenteral nutrition, pain control) during the transfusion. A unit of blood
should not hang for longer than 4 hours because of the danger of bacterial growth. Check the
appearance of blood product for leaks, bubbles, clots, or a purplish color. Do not transfuse
blood if its integrity is compromised. Blood serves as a medium for bacteria.
DIF: Cognitive Level: Application
REF: Text reference: p. 812
OBJ: Demonstrate the following skills on selected patients: initiating blood therapy, implementing
autotransfusion, and monitoring for adverse reactions to transfusion.
TOP: Blood Product Administration
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
14. When a patient’s adverse reaction to a blood transfusion is differentiated, which of the
following signs/symptoms indicates the presence of an anaphylactic response?
a. Wheezing and chest pain
b. Headache and muscle pain
c. Hypotension and tingling of the extremities
d. Crackles in the lungs and increased central venous pressure
ANS: A
Observe the patient for wheezing, chest pain, and possible cardiac arrest. All of these are
indications of an anaphylactic reaction. Be alert to patient complaints of headache or muscle
pain in the presence of a fever. Both may be indicative of a febrile nonhemolytic reaction.
Observe patients receiving massive transfusions for mild hypothermia, cardiac dysrhythmias,
hypotension, and hypocalcemia. Cold blood products can affect the cardiac conduction
system, resulting in ventricular dysrhythmias. Other cardiac dysrhythmias, hypotension, and
tingling may indicate hypocalcemia, which occurs when citrate (used as a preservative for
some blood products) combines with the patient’s calcium. Crackles in the bases of lungs and
rising central venous pressure (CVP) are indications of circulatory overload.
DIF: Cognitive Level: Analysis
REF: Text reference: p. 814
OBJ: Describe various transfusion reactions.
TOP: Anaphylactic Response
KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity
15. The patient is receiving a unit of packed red blood cells (RBCs). Fifteen minutes into the
procedure, he complains of severe kidney pain, and his temperature increases by 3°F. The
nurse stops the transfusion immediately, suspecting that which of the following reactions is
occurring?
a. Delayed hemolytic transfusion reaction
b. Nonhemolytic febrile reaction
c. Acute hemolytic transfusion reaction
d. Severe allergic reaction
ANS: C
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Symptoms of an acute hemolytic reaction usually begin within 15 minutes of transfusion
initiation and include severe pain in the kidney area and chest, increased temperature (up to
105°F), increased heart rate, and a sensation of heat and pain along the vein receiving blood,
as well as chills, low back pain, headache, nausea, chest or back pain, chest tightness,
dyspnea, bronchospasm, anxiety, hypotension, vascular collapse, disseminated intravascular
coagulation, and possibly death. Symptoms of a delayed hemolytic reaction usually begin 2 to
14 days after the transfusion and include unexplained fever, an unexplained decrease in
hemoglobin/hematocrit (Hgb/Hct), increased bilirubin levels, and jaundice. Symptoms of a
nonhemolytic febrile reaction begin between 30 minutes after initiation and 6 hours after
completion of transfusion and include fever greater than 1°C above baseline, flushing, chills,
headache, and muscle pain; they occur most frequently in immunosuppressed patients.
Symptoms of an acute severe allergic reaction usually begin within 5 to 15 minutes of
initiation of transfusion and include coughing, nausea, vomiting, respiratory distress,
wheezing, hypotension, loss of consciousness, and possible cardiac arrest.
DIF: Cognitive Level: Analysis
REF: Text reference: p. 803
OBJ: Describe various transfusion reactions.
TOP: Acute Hemolytic Reaction
KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity
16. The patient has been home from the hospital for 10 days. On the last day of his
hospitalization, he received 2 units of packed red blood cells (RBCs). This morning, he
noticed that his skin had a yellow tint to it and his temperature was elevated. Which reaction
might this patient be experiencing?
a. Delayed hemolytic transfusion reaction
b. Acute hemolytic transfusion reaction
c. Nonhemolytic febrile reaction
d. Severe allergic transfusion reaction
ANS: A
Symptoms of a delayed hemolytic reaction usually begin 2 to 14 days after the transfusion and
include unexplained fever, unexplained decrease in Hgb/Hct, increased bilirubin levels, and
jaundice. Symptoms of an acute hemolytic reaction usually begin within 15 minutes of
transfusion initiation and include severe pain in the kidney area and chest, increased
temperature (up to 105°F), increased heart rate, and increased sensation of heat and pain along
the vein receiving blood, as well as chills, low back pain, headache, nausea, chest or back
pain, chest tightness, dyspnea, bronchospasm, anxiety, hypotension, vascular collapse,
disseminated intravascular coagulation, and possibly death. Symptoms of a nonhemolytic
febrile reaction begin between 30 minutes after initiation and 6 hours after completion of
transfusion and include fever greater than 1°C above baseline, flushing, chills, headache, and
muscle pain; they occur most frequently in immunosuppressed patients. Symptoms of an acute
severe allergic reaction usually begin within 5 to 15 minutes of initiation of transfusion and
include coughing, nausea, vomiting, respiratory distress, wheezing, hypotension, loss of
consciousness, and possible cardiac arrest.
DIF: Cognitive Level: Analysis
REF: Text reference: p. 804
OBJ: Describe various transfusion reactions.
TOP: Delayed Hemolytic Reaction
KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity
17. The specific blood product used for replacement of clotting factors and fibrinogen is:
a. whole blood.
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b. packed RBCs.
c. cryoprecipitate.
d. albumin, 25% pooled.
ANS: C
Cryoprecipitate replaces factors VIII and XIII, von Willebrand’s factor, and fibrinogen. It also
replaces red cell mass and plasma volume and is expected to raise hemoglobin by 1 g/100 mL
and hematocrit by 3% in a non-hemorrhaging adult. Using cryoprecipitate is the preferred
method of replacing red blood cell mass.
DIF: Cognitive Level: Knowledge
REF: Text reference: p. 806
OBJ: Discuss indications for blood therapy.
TOP: Cryoprecipitate
KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity
18. The nurse is administering 1 unit of packed red blood cells as ordered by the primary care
provider. While the nurse is measuring vital signs 15 minutes after starting the transfusion, the
patient complains of chills and back pain. What is the nurse’s first action?
a. Stop the blood transfusion and keep the vein patent by administering saline to
infuse from the other side of the Y tubing.
b. Slow the blood transfusion and notify the charge nurse.
c. Disconnect the blood tubing from the catheter and replace it with an infusion of
normal saline.
d. Stop the blood transfusion and notify the primary care provider.
ANS: C
The nurse’s first priority is to stop the blood transfusion. To keep the intravenous site patent,
normal saline can be infused at a keep-open rate, but the tubing must be changed to avoid
administering more blood as the saline flushes the blood from the tubing. If the tubing is not
changed, additional blood will be administered, and the possible transfusion reaction will
increase. The charge nurse or the primary care provider should be notified only after the
patient has been assessed.
DIF: Cognitive Level: Application
REF: Text reference: p. 811-812
OBJ: Verbalize the skills used in administering blood transfusions.
TOP: Transfusion Reaction
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
MULTIPLE RESPONSE
1. Transfusion therapy is the intravenous (IV) administration of which of the following? (Select
all that apply.)
Whole blood
Plasma products
Red blood cells (RBCs)
Platelets
a.
b.
c.
d.
ANS: A, B, C, D
Transfusion therapy or blood replacement is the intravenous (IV) administration of whole
blood, its components, or plasma-derived product for therapeutic purposes.
DIF: Cognitive Level: Comprehension
REF: Text reference: p. 800
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OBJ: Discuss indications for blood therapy.
TOP: Transfusion Therapy
KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
2. What is the purpose of administering a transfusion? (Select all that apply.)
a. Restore intravascular volume.
b. Restore the oxygen-carrying capacity of blood.
c. Provide clotting factors.
d. Improve blood pressure.
ANS: A, B, C
Transfusions are used to restore intravascular volume with whole blood or albumin, to restore
the oxygen-carrying capacity of blood with red blood cells (RBCs), and to provide clotting
factors and/or platelets. Although increasing blood volume may increase blood pressure,
increasing blood pressure is not a primary objective of transfusion.
DIF: Cognitive Level: Comprehension
REF: Text reference: p. 800
OBJ: Discuss indications for blood therapy.
TOP: Transfusion Therapy
KEY: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity
3. The patient is to receive 2 units of packed red blood cells (RBCs). Before administering the
blood, what does the nurse need to do? (Select all that apply.)
Insert an 18-gauge intravenous (IV) cannula.
Have the patient complete a consent form.
Obtain pretransfusion vital signs.
Notify the physician for a temperature of 37°C.
a.
b.
c.
d.
ANS: B, C
In emergency situations that require rapid transfusions, a large-gauge cannula is preferred;
however, transfusions for therapeutic indications may be infused with cannulas ranging from
20 to 24 gauge. Check that the patient has properly completed and signed transfusion consent
before retrieving blood. Most agencies require patients to sign consent forms before receiving
blood component therapy because of the inherent risks. Obtain and record pretransfusion vital
signs, including temperature, immediately before initiation of the transfusion. If the patient is
febrile (temperature greater than 100°F [37.8°C]), notify the physician or the health care
provider before initiating the transfusion. Change from baseline vital signs during infusion
will alert the nurse to a potential transfusion reaction or adverse effect of therapy.
DIF: Cognitive Level: Application
REF: Text reference: p. 807
OBJ: Demonstrate the following skills on selected patients: initiating blood therapy, implementing
autotransfusion, and monitoring for adverse reactions to transfusion.
TOP: Pretransfusion Procedure
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
4. The patient is receiving blood when he suddenly complains of low back pain and develops
diaphoresis and chills. The nurse should: (Select all that apply.)
stop the transfusion.
start normal saline connected to the Y tubing.
notify the physician.
start normal saline using new intravenous (IV) tubing.
a.
b.
c.
d.
ANS: A, C, D
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If signs of a transfusion reaction occur, stop the transfusion, start normal saline with new
primed tubing directly to the ventricular assist device (VAD) at the keep-vein-open rate
(KVO), and notify the physician immediately.
DIF: Cognitive Level: Application
REF: Text reference: p. 811-812
OBJ: Demonstrate the following skills on selected patients: initiating blood therapy, implementing
autotransfusion, and monitoring for adverse reactions to transfusion.
TOP: Blood Reaction
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
5. Symptoms that indicate an adverse reaction to blood products include which of the following?
(Select all that apply.)
Fever
Skin rash
Hypotension
Cardiac arrest
a.
b.
c.
d.
ANS: A, B, C, D
Symptoms that indicate an adverse reaction range from fever, chills, and skin rash to
hypotension and cardiac arrest.
DIF: Cognitive Level: Knowledge
REF: Text reference: p. 812
OBJ: Describe various transfusion reactions.
TOP: Symptoms of a Blood Product Reaction
KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
COMPLETION
1. A transfusion in which the donor is the patient is known as an
transfusion or
autotransfusion.
ANS:
autologous
In autologous transfusion, or autotransfusion, the donor is the patient.
DIF: Cognitive Level: Knowledge
REF: Text reference: p. 800
OBJ: Discuss indications for blood therapy.
TOP: Autologous Transfusion
KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
2. The presence or absence of specific antigens on the surface of red blood cells determines
in the ABO system.
ANS:
blood type
The presence or absence of specific antigens on the surface of red blood cells determines
blood type in the ABO system.
DIF: Cognitive Level: Knowledge
REF: Text reference: p. 801
OBJ: Describe various transfusion reactions.
TOP: Blood Type
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KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
3. Antibodies that react against the A and B antigens are naturally present in the plasma of
people whose red blood cells do not carry the antigen. These antibodies react against the
foreign antigens. Incompatible red blood cells clump together or
, which
results in a life-threatening hemolytic transfusion reaction.
ANS:
agglutinate
Antibodies that react against the A and B antigens are naturally present in the plasma of
people whose red blood cells do not carry the antigen. These antibodies (agglutinins) react
against the foreign antigens (agglutinogens). Incompatible red blood cells agglutinate (clump
together), which results in a life-threatening hemolytic transfusion reaction.
DIF: Cognitive Level: Knowledge
REF: Text reference: p. 801
OBJ: Describe various transfusion reactions.
TOP: Agglutination
KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
4. The nurse is caring for a patient who is receiving blood while monitoring the patient for
potential complications. The nurse knows that a systemic response to administration of a
blood product that is incompatible with the blood of the recipient, contains allergens to which
the recipient is sensitive or allergic, or is contaminated with pathogens is known as a
.
ANS:
hemolytic reaction
A hemolytic reaction is a systemic response to the administration of a blood product that is
incompatible with the blood of the recipient, contains allergens to which the recipient is
sensitive or allergic, or is contaminated with pathogens.
DIF: Cognitive Level: Knowledge
REF: Text reference: p. 801-802
OBJ: Describe various transfusion reactions.
TOP: Hemolytic Reaction
KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
5. The patient has received blood within the past 6 hours. The patient begins to feel short of
breath and calls for the nurse. The nurse finds that the patient is dusky in color with crackles
throughout his lungs and is coughing up pink frothy sputum. The nurse calls the physician
immediately, knowing that the patient is showing signs of
.
ANS:
transfusion-related acute lung injury (TRALI)
transfusion-related acute lung injury
Possible adverse outcomes that result from transfusion therapy include transmission of
diseases, circulatory overload, and TRALI characterized by noncardiogenic pulmonary edema
with onset within 6 hours of transfusion.
DIF: Cognitive Level: Analysis
REF: Text reference: p. 802|Text reference: p. 814
OBJ: Describe various transfusion reactions.
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TOP: Transfusion-Related Acute Lung Injury (TRALI)
KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
6. Under the ABO system, the blood type
can be given to any individual and is
known as the “Universal Donor.”
ANS:
O negative
O negative can be given to people of any blood type and is known as the “Universal Donor.”
DIF: Cognitive Level: Knowledge
REF: Text reference: p. 802
OBJ: Demonstrate the following skills on selected patients: initiating blood therapy, implementing
autotransfusion, and monitoring for adverse reactions to transfusion.
TOP: Universal Donor
KEY: Nursing Process Step: Evaluation
MSC: NCLEX: Physiological Integrity
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