RN Adult Med Surg Practice NCLEX
2024-2025
What are the findings for acute hemolytic transfusion reaction and time of onset? - ANS chills,
fever, low-back pain, tachycardia, flushing, hypotension, chest tightening or pain, tachypnea,
nausea, anxiety, hemoglobinuria, and impending sense of doom. Immediate or can manifest
during subsequent infusions.
What are the nursing actions for hemolytic transfusion reaction? - ANS 1. Stop transfusion
2. Remove blood from IV access. AVOID infusing further blood products.
3. Initiate an infusion of 0.9% sodium chloride using new tubing
4. monitory vital signs and fluid status
5. Send the blood bag and admin set to lab for testing
Nurse is preparing to administer packed RBCs to a client who has Hgb of 6 g/dL. Which is the
next action to perform during the first 15 minutes of the transfusion? - ANS Assess for
hemolytic transfusion reaction
When can a febrile transfusion reaction happen after a client received blood products? - ANS
Commonly occurs 2 hr after
Name the findings of febrile transfusion reaction - ANS Anti-WBC antibodies, chills (increase of
1·C (2·F) or greater from pretransfusion temp, flushing, hypotension, tachycardia
A nurse is monitoring a client who began receiving a unit of packed RBCs 10 min ago. Which of
the following findings should the nurse identify as an indication of a febrile transfusion reaction?
- ANS Heart rate change from 88/min to 120/min.
Client appears flushed
When can an "allergic" transfusion reaction happen? - ANS During or up to 24 hrs after
What would the nurse notice when a client has allergic transfusion reaction to blood products? -
ANS Mild itching, urticaria, flushing
What nursing actions are performed for mild "allergic" reaction to blood products? - ANS Stop
the transfusion
2024-2025
What are the findings for acute hemolytic transfusion reaction and time of onset? - ANS chills,
fever, low-back pain, tachycardia, flushing, hypotension, chest tightening or pain, tachypnea,
nausea, anxiety, hemoglobinuria, and impending sense of doom. Immediate or can manifest
during subsequent infusions.
What are the nursing actions for hemolytic transfusion reaction? - ANS 1. Stop transfusion
2. Remove blood from IV access. AVOID infusing further blood products.
3. Initiate an infusion of 0.9% sodium chloride using new tubing
4. monitory vital signs and fluid status
5. Send the blood bag and admin set to lab for testing
Nurse is preparing to administer packed RBCs to a client who has Hgb of 6 g/dL. Which is the
next action to perform during the first 15 minutes of the transfusion? - ANS Assess for
hemolytic transfusion reaction
When can a febrile transfusion reaction happen after a client received blood products? - ANS
Commonly occurs 2 hr after
Name the findings of febrile transfusion reaction - ANS Anti-WBC antibodies, chills (increase of
1·C (2·F) or greater from pretransfusion temp, flushing, hypotension, tachycardia
A nurse is monitoring a client who began receiving a unit of packed RBCs 10 min ago. Which of
the following findings should the nurse identify as an indication of a febrile transfusion reaction?
- ANS Heart rate change from 88/min to 120/min.
Client appears flushed
When can an "allergic" transfusion reaction happen? - ANS During or up to 24 hrs after
What would the nurse notice when a client has allergic transfusion reaction to blood products? -
ANS Mild itching, urticaria, flushing
What nursing actions are performed for mild "allergic" reaction to blood products? - ANS Stop
the transfusion
