Blood Transfusion NCLEX Exam Questions With Complete
Solutions
". A unit of packed red blood cells has been prescribed for a
client with low hemoglobin and hematocrit levels. The nurse
notifies the blood bank of the order, and a blood specimen is
drawn from the client for typing and cross-matching. The nurse
receives a telephone call from the blood bank and is informed
that he unit of blood is ready for administration. Arrange the
actions in order of priority that the nurse should take to
administer the blood. (Letter A is the first and letter F is the last
action.)
a) hang the bag of blood
b) obtain the unit of blood from the bank
c) ensure that an informed consent has been signed
d) verify the physician's order for the blood transfusion
e) insert an 18 or 19-gauge IV catheter into the client
f) ask a licensed nurse to assist in confirming blood
compatibility and verifying client identity."
xxxx
xxxx
xxxx
xxx Correct Answers "F, D, B, A, C, E
- The nurse would first verify the physician's order for the blood
transfusion and ensure that the client has been informed about
the procedure and has signed an informed consent. Once this has
been done, the nurse would ensure that at least an 18- or 19-
gauge intravenous needle is inserted into the client. Blood has a
thicker and stickier consistency than intravenous solutions and
using an 18- or 19-gauge catheter ensures that the bore of the
catheter is large enough to prevent damage to the blood cells.
,Next, the blood is obtained from the blood bank, once the nurse
is sure that the client has been informed and has an adequate
access for administering the blood. Once the blood has been
obtained, two registered nurses, or one registered and a licensed
practical nurse (depending on agency policy), must together
check the label on the blood product against the client's
identification number, blood group, and complete name. This
minimizes the risk of error in checking information on the blood
bag and thereby minimizes the risk of harm or injury to the
client. The nurse should measure vital signs and assess lung
sounds and then hang the transfusion."`
xxxxxx
"(from nclex reviewers) The nurse is aware that the following
solutions is routinely used to
flush an IV device before and after the administration of blood
to a
patient is:
"a. 0.9 percent sodium chloride
b. 5 percent dextrose in water solution
c. Sterile water
d. Heparin sodium
xxxxx
xxxxx
xxxxx Correct Answers Correct:" A
"0.9 percent sodium chloride is normal saline. This solution has
the same
osmolarity as blood. Its use prevents red cell lysis. The
solutions
given in options 2 and 3 are hypotonic solutions and can cause
red cell
,lysis. The solution in option 4 may anticoagulate the patient and
result
in bleeding."
xxxxxxxx
"73. A client brought to the emergency department states that he
has
accidentally been taking two times his prescribed dose of
warfarin
(Coumadin) for the past week. After noting that the client has no
evidence of obvious bleeding, the nurse plans to do which of the
following?
1. Prepare to administer an antidote.
2. Draw a sample for type and crossmatch and transfuse the
client.
3. Draw a sample for an activated partial thromboplastin time
(aPTT) level.
4. Draw a sample for prothrombin time (PT) and international
normalized ratio (INR)."
xxxx
xxxx
xxxx Correct Answers Correct - 4 - no rationale
xxx
xx
x
xxx
xxx
xxx
"A month after receiving a blood transfusion an
immunocompromised male patient develops fever, liver
, abnormalities, a rash, and diarrhea. The nurse would suspect this
patient has:
a. Nothing related to the blood transfusion
b. Graft-versus-host disease (GVHD)
c. Myelosuppression
d. An allergic response to a recent medication"
xxx
xxx
xxx Correct Answers Correct: B
GVHD occurs when white blood cells in donor blood attack the
tissues of an immunocompromised recipient. This process can
occur within a month of the transfusion. Options 1 and 4 may be
a thought, but the nurse must remember that
immunocompromised transfusion recipients are at risk for
GVHD
xxxx
xxxx
"Before starting a transfusion of packed red blood cells for an
anemic patient, the nurse would arrange for a peer to monitor his
or her other assigned patients for how many minutes when the
nurse begins the transfusion?
A. 5 minutes
B. 15 minutes
C. 60 minutes
D. 30 minutes"
xxxx
xxx
xxx Correct Answers Correct B
Solutions
". A unit of packed red blood cells has been prescribed for a
client with low hemoglobin and hematocrit levels. The nurse
notifies the blood bank of the order, and a blood specimen is
drawn from the client for typing and cross-matching. The nurse
receives a telephone call from the blood bank and is informed
that he unit of blood is ready for administration. Arrange the
actions in order of priority that the nurse should take to
administer the blood. (Letter A is the first and letter F is the last
action.)
a) hang the bag of blood
b) obtain the unit of blood from the bank
c) ensure that an informed consent has been signed
d) verify the physician's order for the blood transfusion
e) insert an 18 or 19-gauge IV catheter into the client
f) ask a licensed nurse to assist in confirming blood
compatibility and verifying client identity."
xxxx
xxxx
xxxx
xxx Correct Answers "F, D, B, A, C, E
- The nurse would first verify the physician's order for the blood
transfusion and ensure that the client has been informed about
the procedure and has signed an informed consent. Once this has
been done, the nurse would ensure that at least an 18- or 19-
gauge intravenous needle is inserted into the client. Blood has a
thicker and stickier consistency than intravenous solutions and
using an 18- or 19-gauge catheter ensures that the bore of the
catheter is large enough to prevent damage to the blood cells.
,Next, the blood is obtained from the blood bank, once the nurse
is sure that the client has been informed and has an adequate
access for administering the blood. Once the blood has been
obtained, two registered nurses, or one registered and a licensed
practical nurse (depending on agency policy), must together
check the label on the blood product against the client's
identification number, blood group, and complete name. This
minimizes the risk of error in checking information on the blood
bag and thereby minimizes the risk of harm or injury to the
client. The nurse should measure vital signs and assess lung
sounds and then hang the transfusion."`
xxxxxx
"(from nclex reviewers) The nurse is aware that the following
solutions is routinely used to
flush an IV device before and after the administration of blood
to a
patient is:
"a. 0.9 percent sodium chloride
b. 5 percent dextrose in water solution
c. Sterile water
d. Heparin sodium
xxxxx
xxxxx
xxxxx Correct Answers Correct:" A
"0.9 percent sodium chloride is normal saline. This solution has
the same
osmolarity as blood. Its use prevents red cell lysis. The
solutions
given in options 2 and 3 are hypotonic solutions and can cause
red cell
,lysis. The solution in option 4 may anticoagulate the patient and
result
in bleeding."
xxxxxxxx
"73. A client brought to the emergency department states that he
has
accidentally been taking two times his prescribed dose of
warfarin
(Coumadin) for the past week. After noting that the client has no
evidence of obvious bleeding, the nurse plans to do which of the
following?
1. Prepare to administer an antidote.
2. Draw a sample for type and crossmatch and transfuse the
client.
3. Draw a sample for an activated partial thromboplastin time
(aPTT) level.
4. Draw a sample for prothrombin time (PT) and international
normalized ratio (INR)."
xxxx
xxxx
xxxx Correct Answers Correct - 4 - no rationale
xxx
xx
x
xxx
xxx
xxx
"A month after receiving a blood transfusion an
immunocompromised male patient develops fever, liver
, abnormalities, a rash, and diarrhea. The nurse would suspect this
patient has:
a. Nothing related to the blood transfusion
b. Graft-versus-host disease (GVHD)
c. Myelosuppression
d. An allergic response to a recent medication"
xxx
xxx
xxx Correct Answers Correct: B
GVHD occurs when white blood cells in donor blood attack the
tissues of an immunocompromised recipient. This process can
occur within a month of the transfusion. Options 1 and 4 may be
a thought, but the nurse must remember that
immunocompromised transfusion recipients are at risk for
GVHD
xxxx
xxxx
"Before starting a transfusion of packed red blood cells for an
anemic patient, the nurse would arrange for a peer to monitor his
or her other assigned patients for how many minutes when the
nurse begins the transfusion?
A. 5 minutes
B. 15 minutes
C. 60 minutes
D. 30 minutes"
xxxx
xxx
xxx Correct Answers Correct B
