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Flashcards in Blood Transfusions Deck (87)
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1

ANS: C
People with type AB blood have neither antibody and therefore can receive all blood types.
A patient with a history of iron-deficiency anemia who has not taken iron supplements for several years is experiencing increased fatigue and dizziness. What would the nurse expect the patient’s laboratory findings to include?
a. Hematocrit 0.38 (38%)
b. Red blood cell (RBC) count 4,500,000/µL
c. Hemoglobin (Hb) 86 g/L
d. Normal RBC indices

ANS: C
The patient’s clinical manifestations indicate moderate anemia, which is consistent with an Hb of 60 to 100 g/L.

2

When the nurse discusses foods high in iron with a patient who has iron-deficiency anemia, the patient tells the nurse that she prepares low-cholesterol foods for her family and probably does not eat enough meat to meet her iron requirements. It is an appropriate goal for the patient to increase dietary intake of which of the following?
a. Eggs and fish
b. Nuts and cornmeal
c. Milk and milk products
d. Legumes and dried fruit

ANS: D
Legumes and dried fruits are high in iron and low in fat and cholesterol

3

Which one of the following groups of people is at an increased risk for developing iron-deficiency anemia?
a. Postmenopausal women
b. Middle-class people
c. Pregnant women
d. School-aged males

ANS: C
Those at risk for the development of iron-deficiency anemia are premenopausal and pregnant women, people from low socioeconomic backgrounds, older adults, and individuals experiencing blood loss.

4

A 52-year-old patient has pernicious anemia with long-standing weakness and paraesthesia of the feet and hands. The nurse determines that expected outcomes related to knowledge of the therapeutic regimen have been met when the patient states which of the following?
a. “I will need to have cobalamin (B12) injections regularly for the rest of my life.”
b. “I will increase sources of cobalamin (B12), such as muscle meats and liver, in my diet.”
c. “The feeling in my hands and feet will return when my hemoglobin level returns to normal.”
d. “I should plan for only part-time employment because of the chronic fatigue that pernicious anemia causes.”

ANS: A
Pernicious anemia prevents the absorption of vitamin B12, and the patient requires injections or intranasal administration of cobalamin.

5

A patient with chronic lymphocytic leukemia is hospitalized for treatment of severe hemolytic anemia. What is an appropriate nursing intervention for the patient?
a. Provide a diet high in vitamin K and folic acid.
b. Plan care to alternate periods of rest and activity.
c. Isolate the patient from visitors and other patients.
d. Encourage increased intake of fluid and fibre in the diet.

ANS: B
Nursing care for patients with anemia should alternate periods of rest and activity to maintain patient mobility without causing undue fatigue.

6

After teaching the patient about taking oral iron preparations for a moderate iron-deficiency anemia, which of the following patient statements indicates to the nurse that additional instruction is needed?
a. “I will contact my doctor if my stools start to turn black.”
b. “I will call the doctor if the tablets cause a lot of stomach upset.”
c. “I will increase my fluid intake if the iron tablets make me constipated.”
d. “I should take the iron tablets with orange juice about an hour before meals.”

ANS: A
It is normal for the stools to appear black when a patient is taking iron, and the patient should not call the doctor about this.

7

A 42-year-old patient is admitted to the hospital with idiopathic aplastic anemia. What is an appropriate collaborative problem for the nurse to identify for the patient?
a. Potential complication: seizures
b. Potential complication: hemorrhage
c. Potential complication: neurogenic shock
d. Potential complication: pulmonary edema

ANS: B
Because the patient with aplastic anemia has pancytopenia, the patient is at risk for bleeding and infection

8

A patient with sickle cell anemia is admitted to the hospital in crisis with severe abdominal pain. While caring for the patient, what is it most important for the nurse to do?
a. Limit the patient’s intake of oral fluids.
b. Evaluate the effectiveness of narcotic analgesics.
c. Encourage the patient to ambulate as much as tolerated.
d. Teach the patient about high-protein, high-calorie foods.

ANS: B
Pain is the most common clinical manifestation of a crisis and usually requires large doses of continuous opioids for control.

9

A 21-year-old patient is having a sickle cell crisis for the first time in many years. He asks the nurse why the sickling causes such pain. The nurse should explain that the pain of sickling is caused by which of the following?
a. Spasms of the blood cells as they change shape
b. Deposition of sickled red cells in the bone marrow
c. Tissue hypoxia caused by small blood vessel occlusion
d. Bacterial or viral infections of organs that caused the sickling

ANS: C
The pain associated with a sickle cell crisis is caused by ischemia, as the sickled cells occlude small blood vessels and capillaries.

10

During discharge teaching for the patient with neutropenia, which of the following issues should the nurse include?
a. Caffeine and alcohol intake
b. Excessive dietary iron intake
c. Limiting fluids to 2 L per day
d. Exposure to crowds

ANS: D
Patients with neutropenia should be instructed to avoid crowds and people who have colds, flu, or infections. If they are in a public area, they should be taught to wear a mask.

11

A patient who has experienced an acute blood loss exhibits a normal supine blood pressure and pulse at rest but complains of postural hypotension and has a pulse of 110 beats/min when exercising. The nurse knows that these signs and symptoms are manifestations of what percentage of blood loss?
a. 10%
b. 20%
c. 30%
d. 40%

ANS: C
A patient who has experienced an acute blood loss and exhibits a normal supine blood pressure and pulse at rest but complains of postural hypotension and has a pulse of 110 beats/min when exercising has lost approximately 30% of their total blood volume.

12

During the admission assessment of a patient who has an Hb of 4.7 mmol/L (7.6 g/dL) and jaundice of the sclera, what laboratory results would the nurse assess?
a. Stool occult blood
b. Bilirubin level
c. Schilling test
d. Gastric analysis testing

ANS: B
Jaundice is caused by the elevation of bilirubin level associated with RBC hemolysis. The presence of jaundice suggests a hemolytic anemia, rather than gastrointestinal bleeding or cobalamin deficiency, as the cause of the anemia.

13

The physician orders transfusion with packed RBCs for a patient who has severe anemia resulting from a bleeding peptic ulcer. What is the most important nursing action to prevent a transfusion reaction when administering the blood?
a. Verify and document patient identification.
b. Keep the blood chilled during administration.
c. Administer the blood at a rate of no more than 2 mL/min.
d. Stay with the patient during the first 15 minutes of the transfusion.

ANS: A
Improper identification is responsible for 90% of hemolytic transfusion reactions.

14

A patient receiving a transfusion of whole blood develops chills and fever, headache, and anxiety 30 minutes after the transfusion is started. Which of the following does the nurse implement after stopping the transfusion?
a. Send a urine specimen to the laboratory.
b. Administer acetaminophen (Tylenol).
c. Give diphenhydramine (Benadryl).
d. Draw blood for a new crossmatch.

ANS: B
The patient’s clinical manifestations are consistent with a febrile, nonhemolytic transfusion reaction. The transfusion should be stopped and antipyretics administered for the fever as ordered

15

Fifteen minutes after a transfusion of packed RBCs is started, a patient develops tachycardia and tachypnea, and complains of back pain and feeling warm. What is the nurse’s priority action?
a. Discontinue transfusion, and infuse normal saline.
b. Administer oxygen therapy at a high flow rate.
c. Slow the transfusion rate, and reassess the patient in 15 minutes.
d. Stop the blood, and discard the used bag and tubing in a biohazard container.

ANS: A
The first action should be to disconnect the transfusion and infuse normal saline to keep the line open and maintain the patient’s blood pressure. The other actions are also needed but are not the highest priority

16

A patient who has been receiving a heparin infusion and warfarin (Coumadin) for a deep-vein thrombosis is diagnosed with heparin-induced thrombocytopenia and thrombosis syndrome (HITTS). What does the nurse anticipate that the physician will order?
a. Use saline for flushing intravenous (IV) lines.
b. Give low–molecular weight (LMW) heparin.
c. Discontinue the warfarin.
d. Administer platelet transfusions.

ANS: A
All heparin is discontinued when the HITTS is diagnosed. The patient should be instructed never to receive heparin or LMW heparin; therefore, saline will be ordered for flushing IV lines

17

During treatment of the patient with an acute exacerbation of polycythemia vera, what is a critical nursing intervention?
a. Administer oxygen.
b. Evaluate fluid balance.
c. Administer anticoagulants.
d. Administer parenteral iron.

ANS: B
Monitoring hydration status is important during an acute exacerbation because the patient is at risk for fluid overload or underhydration.

18

For which one of the following lab results would the nurse expect to see abnormal results in a patient who has hemophilia?
a. Thrombin time
b. Platelet count
c. Prothrombin time
d. Partial thromboplastin time

ANS: D
Partial thromboplastin time is prolonged in patients with hemophilia because of a deficiency in any intrinsic clotting system factor. Prothrombin time, thrombin time, and platelet count are expected to be normal in a patient with hemophilia

19

Of the following patients waiting to be admitted by the emergency department nurse, which one requires the most rapid assessment and care by the nurse?
a. The patient with a history of sickle cell anemia who has had nausea and diarrhea for 24 hours
b. The patient who has chemotherapy-induced neutropenia and a temperature of 38°C
c. The patient with thrombocytopenia who has oozing after having a tooth extracted
d. The patient with hemophilia A who has ankle swelling after twisting the ankle

ANS: B
A neutropenic patient with a fever is assumed to have an infection and is at risk for rapidly developing sepsis. Rapid assessment, cultures, and initiation of antibiotic therapy are needed.

20

While a patient with severe acquired thrombocytopenia is receiving platelet transfusions, the nurse recognizes that a platelet transfusion reaction may be present when the patient experiences which of the following signs?
a. Flushing, itching, and urticaria
b. Sudden onset of chills and fever
c. Urticaria, wheezing, and hypotension
d. Tachycardia, tachypnea, and hemoglobinuria

ANS: B
Sudden onset of both chills and fever indicates a transfusion reaction.

21

The nurse identifies a nursing diagnosis of risk for injury related to medical interventions for a patient with immune thrombocytopenic purpura. What is an appropriate nursing intervention that addresses the etiology of this nursing diagnosis?
a. Use a soft-bristled toothbrush and cotton swabs for mouth care.
b. Limit the number of venipunctures by using an intermittent-infusion device.
c. Assess the patient during the platelet transfusion for symptoms of transfusion reactions.
d. Assess the patient’s mucous membranes and skin each shift to detect the presence of bleeding.

ANS: B
Limit the number of venipunctures; intramuscular or subcutaneous injections should be avoided because of the risk for bleeding.

22

When preparing a patient for a blood transfusion, the nurse will prepare the blood. Which IV solution would the nurse prepare to administer in a Y-type tubing adjacent to the blood?
a. Dextrose 5%
b. Lactated Ringer’s
c. Normal saline
d. Dextrose 10%

ANS: C
When preparing a patient for a blood transfusion, the nurse will prepare the blood and attach normal saline to Y-type tubing adjacent to the blood for administration.

23

A patient with type A hemophilia has been admitted to the hospital with severe pain and swelling in his right knee. To prevent joint deformity during the initial care of the patient, what should the nurse do?
a. Immobilize the knee.
b. Elevate the right lower limb on pillows.
c. Perform passive range of motion to the knee.
d. Have the patient perform isometric exercises of the affected leg against a footboard.

ANS: A
The initial action should be total rest of the knee to minimize bleeding.

24

Laboratory studies related to coagulation are performed on a patient with a bleeding disorder. The nurse explains to the patient that von Willebrand’s disease can be differentiated from other types of hemophilia by evaluating which of the following laboratory results?
a. Bleeding time
b. Platelet count
c. Prothrombin time
d. Partial thromboplastin time

ANS: A
The bleeding time is affected by von Willebrand’s disease. Platelet count, prothrombin time, and partial thromboplastin time are normal in von Willebrand’s disease.

25

When caring for a patient with hemophilia, the nurse teaches the patient to seek immediate medical attention on experiencing which of the following signs?
a. Fever
b. A sore throat
c. Bleeding gums
d. Dark, tarry stools (melena)

ANS: D
Melena is a sign of gastrointestinal bleeding and requires further assessment.

26

A patient’s family member asks the nurse what caused the patient to develop disseminated intravascular coagulation (DIC). What does the nurse tell the family member about DIC?
a. It is caused by an abnormal activation of clotting.
b. It occurs when the immune system attacks platelets.
c. It is a complication of cancer chemotherapy.
d. It is caused when hemolytic processes destroy erythrocytes.

ANS: A
DIC is an abnormal response of the clotting cascade stimulated by a variety of diseases or disorders

27

During treatment of the patient who has sepsis-induced DIC with moderate bleeding, on what would the nurse expect the initial collaborative care will focus?
a. Administration of heparin to reduce intravascular clotting
b. Treatment of the infectious process with IV antibiotics
c. Infusion of whole blood to replace clotting factors and RBCs
d. Supportive management of symptoms until the DIC is resolved

ANS: B
Treatment of the acute sepsis is essential to resolving the DIC and will be the major focus of collaborative care. Heparin administration is controversial in DIC, although it may be used if the DIC does not resolve and clotting factors continue to decrease.

28

A patient with myelodysplastic syndrome has laboratory values that indicate total bone marrow suppression. The nurse identifies a nursing diagnosis of risk for infection based on which of the following findings?
a. Basophils 120 cells/mL
b. Monocytes 360 cells/mL
c. Neutrophils 4000 cells/mL
d. White blood cell (WBC) count 2.8 × 109 cells/L (2800 cells/microlitre)

ANS: D
The low WBC count indicates a risk for infection. The nurse should notify the physician and expect an order to check the differential WBC count.

29

What is the most appropriate nursing intervention to assess for the presence of infection in a patient with neutropenia?
a. Monitor WBCs daily.
b. Monitor temperature every 4 hours.
c. Monitor the skin for temperature and diaphoresis.
d. Monitor the mouth and perianal area every shift for signs of redness and swelling.

ANS: B
The earliest sign of infection in a neutropenic patient is an elevation in temperature. Patients with neutropenia (low neutrophil count) are susceptible to infection and may be febrile.

30

A patient receiving chemotherapy for acute lymphocytic leukemia has pancytopenia, and filgrastim (Neupogen) is prescribed. The nurse teaches the patient that the reason for the use of the medication is which of the following?
a. Remission of the leukemia
b. Improvement in the number and function of neutrophils
c. Replacement of abnormal stem cells in the bone marrow with normal cells
d. Prevention of hemorrhage complications in patients with thrombocytopenia

ANS: B
Filgrastim increases the neutrophil count and function in neutropenic patients.