1. List 3 objectives for blood transfusion.
Replace lost volume
Replace low Hgb
Improve oxygenation if low
2. Define the following terms
a. Agglutinin
An agglutinin is a substance that causes particles to coagulate to form
a thickened mass Agglutinins can be antibodies that cause antigens to
aggregate by binding to the antigen-binding sites of antibodies
b. Antigen
An antigen is a substance/molecule that, when introduced into the
body, triggers the production of an antibody by the immune system, which will
then kill or neutralize the antigen that is recognized as a foreign and potentially
harmful invader.
c. Autologous donor
Self donor of blood for own surgery
d. ABO
Universal blood typing system that identifies antigens on RBC’s
e. Rh
Individuals either have, or do not have, the "Rhesus factor" on the surface of
their red blood cells.
The Rh blood group system currently consists of 50 defined blood-group
3. The universal donor has the blood group _____O neg_______________.
4. The blood group of the universal recipient is ___AB+_______________.
5. The nurse must check which of the following with another nurse before
initiating the transfusion?
a. ABO and Rh
b. Patient name.
c. Unit number on compatibility tag.
d. Expiration date.
e. All of the above.
Copyright 2011, Keith Rischer/
6. The recommended rate of infusion for a unit of whole blood or packed
RBC’s is ___2____ hrs, but not longer than ______4____hrs.
7. Clients particularly at risk for circulatory overload are _renal
disease_____________, ____heart failure____________, and
8. Needle size for blood transfusion is #____18_____ to #__20___________
9. Infusion for blood must always have a ___NS___________ and a
__blood__________ administration set.
10. The client is particularly at risk for a transfusion reaction during the first
15 minutes. List nursing action you will do to monitor the client for
signs/symptoms of a reaction.
1. double check all required components with second RN
2. VS at baseline especially temp and 15”, every hour of infusion, and end
3. Slow rate to ½ ordered first 15”
4. Stay with patient first 15” to observe
11. List 5 signs and symptoms most commonly associated with transfusion
e. hypotension-hemolytic
12. IV tubing should always be primed with which IV solution?
Cell lysis
13. Nursing actions for blood transfusion reaction
STOP transfusion stat & disconnect
Maintain IV site-disconnect from IV and flush with NS
Recheck ID
Notify blood bank/MD
Monitor VS
Treat sx per MD orders
Save bag and tubing-send to blood bank
Document per policy