ACE YOUR NUR 211 BLOOD TRANSFUSION EXAM: COMPLETE
STUDY GUIDE WITH COMPREHENSIVE QUESTIONS AND ANSWERS
LATEST 2026/2027
◉ The physician orders 2 units of packed RBCs to be administered to
the client. At 0600 the night shift nurse initiates the first unit's
transfusion before going off shift. At 1000 the day shift nurse notes the
IV line has clotted off and the transfusion has not been completed. The
nursing assessment revealed the transfusion was only approximately
75% complete. Which of the actions by the nurse is most appropriate?
A. Advise the blood bank about the delay for the next unit.
B. Restart another peripheral line with 0.9% NS and restart the
blood transfusion with the remaining blood unit. C.
Discontinue the transfusion.
D. Document the amount infused thus far and continue the transfusion.
Answer C
Rationale: A unit of blood should be administered within a 4 hour
period of time. The nurse should discontinue the transfusion,
document the findings and notify the blood bank. The agency policy
will need to be followed concerning the documentation process and
notification of appropriate personnel. Continuing the transfusion
with the "open" unit will expose the client to an increase risk of
injury.
,◉ The client with O+ blood is in need of an emergency transfusion but
the lab does not have any O+ blood available. Which potential unit of
blood could be given to the client?
1. 0- unit
2. A+ unit
3. B+ unit
4. Any Rh+ unit Correct answer: Answer 1.
1. O- negative blood is considered the universal donor because it does
not contain the antigens A, B, or Rh. (AB+ is considered the
universal recipient because a person with this blood type has all the
anti-gens on the blood).
2.A+ blood contains the antigen A that the client will react to,
causing the development of antibodies. The unit being Rh+ is
compatible with the client.
3.B+ blood contains the antigen B that the client will react to, causing
the development of anti-bodies. The unit being Rh+ is compatible
with the client.
4.This client does not have antigens A or B on the blood. Administration
of these types would cause an antigen/antibody reaction within the
client's body, resulting in a massive hemolysis of the client's blood and
death."
, ◉ About ten minutes after the nurse begins an infusion of packed RBCs,
the patient complains of chills, chest and back pain, and nausea. His face
is flushed, and he's anxious. Which is the priority nursing action?
1. Administering antihistamines STAT for an allergic reaction.
2. Notifying the physician of a possible transfusion reaction.
3. Obtaining a urine and serum specimen to send to the lab immediately.
4. Stopping hte transfusion and maintaining a patent IV catheter. The
correct answer is 4. The patient is experiencing a transfusion reaction.
The immediate nursing action is to stop the transfusion and maintain a
patent IV line. The other options may be indicated but aren't the
priority in this case.
◉ The nurse is administering packed red blood cells (PRBCs) to a client.
The nurse should first:
1. Discontinue the I.V. catheter if a blood transfusion reaction occurs.
2. Administer the PRBCs through a percutaneously inserted central
catheter line with a 20-gauge needle.
3. Flush PRBCs with 5% dextrose and 0.45% normal saline solution.
4. Stay with the client during the first 15 minutes of infusion. Correct: 4
The most likely time for a blood transfusion reaction to occur is
during the first 15 minutes or first 50 mL of the infusion. If a blood
transfusion reaction does occur, it is imperative to keep an established
I.V. line so that medication can be administered to prevent or treat
STUDY GUIDE WITH COMPREHENSIVE QUESTIONS AND ANSWERS
LATEST 2026/2027
◉ The physician orders 2 units of packed RBCs to be administered to
the client. At 0600 the night shift nurse initiates the first unit's
transfusion before going off shift. At 1000 the day shift nurse notes the
IV line has clotted off and the transfusion has not been completed. The
nursing assessment revealed the transfusion was only approximately
75% complete. Which of the actions by the nurse is most appropriate?
A. Advise the blood bank about the delay for the next unit.
B. Restart another peripheral line with 0.9% NS and restart the
blood transfusion with the remaining blood unit. C.
Discontinue the transfusion.
D. Document the amount infused thus far and continue the transfusion.
Answer C
Rationale: A unit of blood should be administered within a 4 hour
period of time. The nurse should discontinue the transfusion,
document the findings and notify the blood bank. The agency policy
will need to be followed concerning the documentation process and
notification of appropriate personnel. Continuing the transfusion
with the "open" unit will expose the client to an increase risk of
injury.
,◉ The client with O+ blood is in need of an emergency transfusion but
the lab does not have any O+ blood available. Which potential unit of
blood could be given to the client?
1. 0- unit
2. A+ unit
3. B+ unit
4. Any Rh+ unit Correct answer: Answer 1.
1. O- negative blood is considered the universal donor because it does
not contain the antigens A, B, or Rh. (AB+ is considered the
universal recipient because a person with this blood type has all the
anti-gens on the blood).
2.A+ blood contains the antigen A that the client will react to,
causing the development of antibodies. The unit being Rh+ is
compatible with the client.
3.B+ blood contains the antigen B that the client will react to, causing
the development of anti-bodies. The unit being Rh+ is compatible
with the client.
4.This client does not have antigens A or B on the blood. Administration
of these types would cause an antigen/antibody reaction within the
client's body, resulting in a massive hemolysis of the client's blood and
death."
, ◉ About ten minutes after the nurse begins an infusion of packed RBCs,
the patient complains of chills, chest and back pain, and nausea. His face
is flushed, and he's anxious. Which is the priority nursing action?
1. Administering antihistamines STAT for an allergic reaction.
2. Notifying the physician of a possible transfusion reaction.
3. Obtaining a urine and serum specimen to send to the lab immediately.
4. Stopping hte transfusion and maintaining a patent IV catheter. The
correct answer is 4. The patient is experiencing a transfusion reaction.
The immediate nursing action is to stop the transfusion and maintain a
patent IV line. The other options may be indicated but aren't the
priority in this case.
◉ The nurse is administering packed red blood cells (PRBCs) to a client.
The nurse should first:
1. Discontinue the I.V. catheter if a blood transfusion reaction occurs.
2. Administer the PRBCs through a percutaneously inserted central
catheter line with a 20-gauge needle.
3. Flush PRBCs with 5% dextrose and 0.45% normal saline solution.
4. Stay with the client during the first 15 minutes of infusion. Correct: 4
The most likely time for a blood transfusion reaction to occur is
during the first 15 minutes or first 50 mL of the infusion. If a blood
transfusion reaction does occur, it is imperative to keep an established
I.V. line so that medication can be administered to prevent or treat
