NCLEX Practice Exam for Blood Transfusion

EXPLANATION

✔Correct answer:

Advising the patient to immediately report any itching, chest pain, or difficulty breathing. The most critical intervention Nurse Taylor should prioritize is advising the patient to immediately report any signs or symptoms of a transfusion reaction, such as itching, chest pain, or difficulty breathing. Transfusion reactions can range from mild allergic responses to severe, life-threatening conditions like anaphylaxis or hemolytic reactions. Early identification of these symptoms is vital for prompt intervention, which may include stopping the transfusion, administering medications (e.g., antihistamines, corticosteroids, epinephrine), and providing supportive care to stabilize the patient.

During a blood transfusion, the patient may experience a reaction if their immune system recognizes the transfused blood as foreign. This can lead to a cascade of immune responses, causing symptoms such as hives, fever, chills, chest pain, shortness of breath, or anaphylaxis. Recognizing these early signs allows for the immediate cessation of the transfusion and initiation of appropriate treatment, which can prevent more severe complications.

Imagine you're filling a car with gasoline, and you notice a strong smell of fuel or see a leak. Just as you would stop filling the tank immediately to prevent a fire, the patient should alert the nurse at the first sign of a transfusion reaction to prevent serious complications.

Nurses should closely monitor the patient, particularly within the first 15 minutes of the transfusion, as most acute reactions occur during this time. Additionally, nurses should ensure that:

• The patient understands the importance of reporting any unusual symptoms immediately.
• Vital signs are taken before, during, and after the transfusion, with particular attention to any changes.
• The correct blood type and crossmatch results are verified before starting the transfusion.
• The transfusion is started slowly to monitor for any immediate reactions before increasing the rate.
• The patient is educated about the potential risks and signs of a transfusion reaction.

✘Incorrect answer options:

Warming the blood before the transfusion begins. While blood can be warmed before transfusion in specific cases (e.g., large-volume transfusions or in patients with cold agglutinin disease), it is not a routine priority for all transfusions. Warming is done to prevent hypothermia, but it is not a first-line intervention for ensuring safety against transfusion reactions.

Explaining to the patient that the transfusion typically lasts 4 to 6 hours. Providing information about the duration of the transfusion is important for patient education, but it is not the most critical safety intervention. The patient's understanding of how to recognize and report a transfusion reaction is far more crucial to ensuring their immediate safety.

Recording the blood administration details in the patient’s chart. Accurate documentation is essential for legal and clinical purposes, but this action should follow after ensuring the patient’s safety. Documentation alone does not prevent or manage transfusion reactions, which can be life-threatening if not promptly addressed.

EXPLANATION

✔Correct answer:

Blood expiration date. Nurse Patel should check the blood expiration date to ensure the viability of the blood cells before administering a unit of blood. The expiration date on a blood product indicates the last day the blood is considered safe and effective for transfusion. Blood cells have a limited shelf life due to the breakdown of red blood cells over time, which can lead to hemolysis and a decrease in their oxygen-carrying capacity. Using blood that is past its expiration date increases the risk of complications such as transfusion reactions, decreased efficacy of the transfusion, and potential harm to the patient.

Red blood cells (RBCs) undergo changes as they age, including the loss of membrane integrity, decreased flexibility, and increased susceptibility to hemolysis. The storage of blood under refrigerated conditions slows these processes but does not stop them. Blood stored for longer periods is more likely to contain higher levels of potassium (due to cell lysis) and other metabolic byproducts, which can be harmful if transfused. The expiration date is carefully determined based on these factors to ensure that the blood is transfused while it is still safe and effective.

Think of the expiration date on blood like the "use by" date on perishable food. Just as you wouldn't eat food that is past its expiration date due to the risk of spoilage, you shouldn't use blood past its expiration date due to the risk of reduced efficacy and safety.

Before administering the blood, Nurse Patel should:

• Verify that the blood is within its expiration date and has not been stored for too long.
• Check the blood for any signs of contamination, such as discoloration, clots, or unusual odors.
• Ensure proper storage of the blood until it is ready for use, typically in a blood bank refrigerator.
• Document all information related to the blood product, including the expiration date, to maintain accurate records.
• Follow the facility’s protocols for returning or discarding expired blood products.

✘Incorrect answer options:

Blood type. The blood type indicates the ABO and Rh classification of the blood, which is essential for compatibility with the recipient but does not provide information about the age or viability of the blood cells.

Blood group. Similar to blood type, the blood group refers to the ABO and Rh system and ensures compatibility, but it does not inform the nurse about the age of the blood cells or their viability.

Blood identification number. The blood identification number is used to track and match the blood product to the specific patient and to ensure traceability, but it does not provide information about the age or condition of the blood cells.

EXPLANATION

✔Correct answer:

Stop the transfusion. The first action Nurse Evans should take when the patient begins to experience difficulty breathing, flushed skin, and chills during a transfusion is to stop the transfusion immediately. These symptoms are indicative of a potential acute transfusion reaction, which could range from a mild allergic reaction to a more severe and life-threatening complication like an acute hemolytic reaction or anaphylaxis. Stopping the transfusion is the most critical step to prevent further administration of the potentially harmful blood product, thereby reducing the risk of worsening the patient's condition.

Transfusion reactions can occur when the patient's immune system reacts against antigens in the donor blood. This reaction can lead to the destruction of transfused red blood cells, release of inflammatory cytokines, and activation of the complement system, resulting in symptoms like difficulty breathing, fever, chills, and flushed skin. If the transfusion is not stopped immediately, these reactions can escalate, leading to severe complications such as shock, acute kidney injury, or disseminated intravascular coagulation (DIC).

If you're filling a glass with water and notice it starting to crack, the first thing you do is stop pouring to prevent further damage. Similarly, when signs of a transfusion reaction appear, the first step is to stop the transfusion to prevent the patient from getting more of the problematic blood.

After stopping the transfusion, Nurse Evans should:

• Maintain the IV line with normal saline using new tubing to keep the vein open, while avoiding flushing the existing blood product into the patient’s circulation.
• Notify the physician immediately and prepare for emergency interventions, which may include administering oxygen, antihistamines, corticosteroids, or epinephrine depending on the severity of the reaction.
• Monitor the patient’s vital signs closely, particularly blood pressure, heart rate, and oxygen saturation.
• Collect the blood product, tubing, and IV fluids for return to the blood bank for further testing, as part of the investigation into the reaction.
• Document the event thoroughly, including the patient’s symptoms, the actions taken, and the patient’s response to those actions.

✘Incorrect answer options:

Administer oxygen. While administering oxygen may be necessary depending on the patient's symptoms, the first and most crucial action is to stop the transfusion to prevent further introduction of the triggering antigen into the patient’s system.

Place the client under a droplight. Placing the patient under a droplight is not relevant to managing a transfusion reaction and would not address the underlying issue. It is not a standard intervention in this context.

Check the client’s temperature. Although checking the temperature is important in assessing a febrile reaction, the immediate priority is to stop the transfusion to prevent any further complications.

EXPLANATION

✔Correct answer:

15 minutes. Nurse Parker should remain with the patient for the first 15 minutes after starting the transfusion of packed red blood cells. The first 15 minutes are critical because this is when most acute transfusion reactions occur, such as allergic reactions, febrile non-hemolytic reactions, or more severe reactions like acute hemolytic reactions and anaphylaxis. By staying with the patient during this time, the nurse can promptly identify and respond to any signs of a transfusion reaction, such as fever, chills, itching, hives, back pain, chest pain, or shortness of breath.

During a blood transfusion, the recipient’s immune system may react against the donor blood, leading to various types of transfusion reactions. These reactions can cause a range of symptoms, from mild allergic responses to severe hemolysis, where the red blood cells are rapidly destroyed. Early detection and intervention are crucial to preventing the progression of a reaction that could lead to life-threatening complications, such as shock or renal failure.

Imagine you're turning on a new car for the first time. You don’t immediately hit the gas and drive off; instead, you let the engine run for a few minutes to listen for any strange noises or issues. This initial period lets you catch any problems before they become serious. Similarly, during the first 15 minutes of a blood transfusion, the nurse stays with the patient to "listen" for any signs of a reaction, ensuring everything is running smoothly before proceeding further.

During the first 15 minutes of the transfusion, Nurse Parker should:

• Start the transfusion slowly to allow for close monitoring of the patient’s response.
• Continuously observe the patient for any signs of a transfusion reaction, such as changes in vital signs, discomfort, or unusual symptoms.
• Be prepared to stop the transfusion immediately if any signs of a reaction occur, and follow the protocol for managing transfusion reactions, which may include notifying the physician, administering medications, and providing supportive care.
• After the initial 15 minutes, if no reaction has occurred, the transfusion rate may be increased to the prescribed rate, and periodic monitoring should continue.

✘Incorrect answer options:

30 minutes. While ongoing monitoring is important throughout the transfusion, remaining with the patient for 30 minutes is not necessary unless there are specific concerns. The critical period for most acute reactions is within the first 15 minutes.

45 minutes. Remaining with the patient for 45 minutes is excessive for routine monitoring. The initial 15 minutes are the most crucial for detecting acute transfusion reactions, and ongoing monitoring can be done at regular intervals afterward.

60 minutes. While it is important to monitor the patient throughout the transfusion, staying with the patient for 60 minutes continuously is unnecessary for routine transfusions. The nurse should focus on the first 15 minutes and then continue to monitor the patient periodically.

EXPLANATION

✔Correct answer:

Checking the patient's vital signs. Before starting a blood transfusion, Nurse Lee should prioritize checking the patient’s vital signs. This is critical because baseline vital signs provide a reference point to identify any changes that may occur during the transfusion, which could indicate a transfusion reaction. Any significant changes in temperature, heart rate, blood pressure, or respiratory rate could be early signs of a transfusion reaction, such as a febrile non-hemolytic reaction, acute hemolytic reaction, or anaphylaxis.

Blood transfusions carry the risk of immune reactions, ranging from mild allergic reactions to severe hemolytic or anaphylactic reactions. Monitoring vital signs before, during, and after the transfusion helps in the early detection of these reactions. For instance, an increase in temperature might suggest a febrile reaction, while a drop in blood pressure could indicate a more severe hemolytic reaction. Immediate identification and response are crucial to prevent further complications.

Think of checking vital signs before a blood transfusion like checking the weather before a long road trip. You want to know what to expect and be prepared for any sudden changes that could affect your journey. Similarly, baseline vital signs prepare the nurse for any "storms" that might arise during the transfusion.

Nurses should take and document vital signs immediately before starting the transfusion, 15 minutes after starting, and then periodically throughout the transfusion. The patient should also be closely observed for any signs or symptoms of a transfusion reaction.

• Instruct the patient to report any unusual symptoms immediately, such as chills, back pain, or shortness of breath.
• Monitor the patient for at least 15 minutes after starting the transfusion, as most acute reactions occur during this time.
• Ensure that emergency medications and equipment, such as epinephrine and oxygen, are readily available.
• Stop the transfusion immediately if any signs of a reaction occur, and notify the healthcare provider.

✘Incorrect answer options:

Monitoring the patient’s intake and output. While monitoring intake and output is important for assessing fluid balance, it is not the immediate priority before starting a blood transfusion. Vital signs take precedence as they provide immediate data on the patient's current physiological state and the potential for a transfusion reaction.

Confirming the NPO status of the patient. Confirming NPO (nothing by mouth) status is relevant in preoperative care or when specific procedures are planned, but it is not directly related to the safety of administering a blood transfusion.

Assessing the patient’s skin turgor. Skin turgor is used to assess hydration status, which is important in overall patient care, but it is not directly related to the immediate safety concerns of a blood transfusion. Monitoring vital signs is far more critical in this context.

EXPLANATION

✔Correct answer:

Coagulation studies. Nurse Lee should focus on coagulation studies to evaluate the effectiveness of the cryoprecipitate transfusion. Cryoprecipitate is a blood product rich in clotting factors, particularly fibrinogen, Factor VIII, von Willebrand factor, and Factor XIII. It is typically administered to patients with conditions that affect blood clotting, such as hemophilia, disseminated intravascular coagulation (DIC), or massive hemorrhage where fibrinogen levels are low. Monitoring coagulation studies, such as fibrinogen levels, prothrombin time (PT), activated partial thromboplastin time (aPTT), and bleeding time, provides critical information on how well the patient’s blood is clotting after receiving cryoprecipitate.

Coagulation is the process by which the blood forms clots to prevent excessive bleeding. In patients with low fibrinogen or other clotting factor deficiencies, the ability to form a stable clot is impaired. Cryoprecipitate replenishes these essential clotting factors, helping to restore normal clotting function. By evaluating coagulation studies before and after the transfusion, Nurse Lee can assess whether the treatment has successfully improved the patient’s ability to clot blood, which is the primary goal of administering cryoprecipitate.

Imagine you’re baking a cake and realize the batter is too runny, so you add flour to thicken it. After mixing, you check the consistency to see if it’s just right. Similarly, when a patient receives cryoprecipitate to improve their blood’s ability to clot, coagulation studies are like checking the consistency of the batter—they tell you if the "recipe" for clotting is correct and if the treatment is working as intended.

When administering cryoprecipitate, Nurse Lee should:

• Ensure that baseline coagulation studies are obtained before the transfusion to compare with post-transfusion results.
• Monitor the patient for any signs of bleeding or clotting abnormalities during and after the transfusion.
• Assess for any transfusion reactions and manage them promptly if they occur.
• Document the patient’s response to the transfusion and any changes in coagulation study results.
• Communicate with the healthcare team about the effectiveness of the transfusion based on the laboratory results and clinical findings.

✘Incorrect answer options:

Serum electrolytes. Serum electrolytes (e.g., sodium, potassium, chloride) are not directly impacted by cryoprecipitate and do not provide information on the effectiveness of the transfusion in improving coagulation.

White blood cell count. The white blood cell (WBC) count is related to the immune system and infection control, but it does not reflect the efficacy of cryoprecipitate, which is used to correct clotting factor deficiencies.

Hematocrit levels. Hematocrit measures the proportion of red blood cells in the blood and is typically used to assess anemia or blood loss. It is not a relevant measure for evaluating the effectiveness of cryoprecipitate, which is focused on improving clotting function.

EXPLANATION

✔Correct answer:

Opt for an autologous blood donation. Nurse Carter should suggest that the patient opt for an autologous blood donation. An autologous blood donation involves the patient donating their own blood prior to surgery. This blood is then stored and can be used during or after surgery if a transfusion is necessary. Using the patient’s own blood significantly reduces the risk of transfusion reactions because the blood is fully compatible with the patient's immune system. This eliminates the risk of alloimmunization, which occurs when the immune system reacts against foreign antigens in donor blood, and also reduces the risk of transmitting infectious diseases.

Transfusion reactions can occur when the recipient’s immune system identifies foreign antigens on transfused donor red blood cells and mounts an immune response. This can lead to mild to severe reactions, including hemolysis (destruction of red blood cells), febrile reactions, and even anaphylaxis. By using the patient’s own blood (autologous donation), these risks are effectively minimized, as the body recognizes its own blood cells and does not mount an immune response against them.

Think of it like bringing your own food to a picnic. You know it's safe and exactly to your taste, avoiding any chance of a reaction to something unfamiliar that someone else might bring.

If the patient opts for autologous blood donation, Nurse Carter should:

• Coordinate with the blood bank to schedule the donation at an appropriate time before surgery.
• Ensure the patient understands the process and timeline, as autologous donations are typically made several weeks before the surgery.
• Monitor the patient’s hemoglobin levels after the donation to ensure they remain within a safe range for surgery.
• Document the donation and ensure the blood is properly labeled and reserved for the patient’s use.
• Educate the patient on the potential benefits of autologous donation, including the reduced risk of transfusion reactions.

✘Incorrect answer options:

Ask the blood bank to screen any donated blood twice. While blood banks rigorously screen donated blood for infectious diseases and compatibility, additional screening does not eliminate the risk of transfusion reactions, as reactions can still occur due to minor antigen differences between donor and recipient.

Start iron supplements and consume more green leafy vegetables before surgery. Increasing iron intake may help improve hemoglobin levels but does not address the risk of transfusion reactions. Iron supplements and diet changes do not prevent immune reactions to transfused blood.

Arrange for a family member to donate blood. Directed donations from family members might seem safer, but the blood still has to be crossmatched, and there is no guarantee of compatibility or reduced reaction risk. Furthermore, there is still a risk of alloimmunization or other transfusion-related complications.

EXPLANATION

✔Correct answer:

Tubing with an in-line filter. When administering packed red blood cells (PRBCs), Nurse Thompson should use tubing with an in-line filter. This type of tubing is specifically designed for blood transfusions and includes a filter that removes clots, debris, and other potentially harmful particles that might be present in the blood product. The in-line filter is crucial for preventing complications such as embolism or immune reactions that can occur if particulate matter enters the patient’s circulation. The tubing also ensures the proper flow rate and the safe administration of blood components.

Blood products, including PRBCs, may contain small clots or debris formed during storage. If these particles are not filtered out, they can cause blockages in the patient’s blood vessels or provoke an immune response, leading to complications like pulmonary embolism, febrile reactions, or even hemolysis. The in-line filter helps to protect the patient by ensuring that only the purified blood product reaches their circulation.

Think of the in-line filter in blood tubing like a sieve you use when pouring soup into a bowl—it catches any unwanted pieces, ensuring that only the smooth liquid (or in this case, the safe blood product) is delivered to the patient.

Before starting the transfusion, Nurse Thompson should:

• Verify the compatibility of the blood type and crossmatch results.
• Prime the tubing with normal saline to prevent hemolysis of the blood cells.
• Ensure the in-line filter is correctly positioned and free of air bubbles.
• Monitor the patient closely, especially during the first 15 minutes, for any signs of transfusion reactions.
• Document the blood transfusion process, including vital signs, patient reactions, and the use of the in-line filter.

✘Incorrect answer options:

Microfusion set. A microfusion set is used for the precise administration of small volumes of fluid or medication, not for blood transfusions. It is not equipped with the necessary in-line filter to ensure safe blood transfusion.

Polyvol Pro Burette Set. A burette set is typically used for controlled administration of intravenous fluids and medications, particularly in pediatrics, but it is not designed for transfusing blood products. It lacks the in-line filter required for blood transfusions.

Photofusion set. A photofusion set is not a standard term in medical practice related to blood transfusions, and it is not relevant to the administration of PRBCs. It is likely a distractor in this context and does not serve the function of safe blood transfusion.

EXPLANATION

✔Correct answer:

Supply clotting factors and assist with volume expansion. The primary reason for administering Fresh Frozen Plasma (FFP) in a patient who has suffered significant blood loss is to supply clotting factors and assist with volume expansion. FFP contains a wide range of coagulation factors, including fibrinogen, prothrombin, and other vital proteins necessary for blood clotting. In cases of significant blood loss, the body can become depleted of these clotting factors, which are essential to stop bleeding and stabilize the patient. Additionally, FFP can help with volume expansion, which is crucial in maintaining adequate circulatory volume and perfusion in a patient who has experienced significant blood loss.

When a patient experiences significant blood loss, they not only lose red blood cells but also plasma, which contains clotting factors essential for the coagulation cascade. If these factors are not replaced, the patient is at risk of developing coagulopathy, where their blood is unable to clot properly, leading to further bleeding. FFP is used to replenish these factors and restore the blood's ability to clot, which is critical in preventing continued hemorrhage and stabilizing the patient.

Think of the blood as a dam holding water (blood). If the dam has a leak (blood loss), the water (blood) not only escapes, but the structure (clotting factors) that holds it together weakens. FFP is like adding concrete to the dam—it helps plug the leak and strengthens the dam, preventing it from collapsing further.

Before administering FFP, the nurse should ensure that:

• Blood type and crossmatch are correctly verified to avoid transfusion reactions.
• Baseline vital signs are obtained and monitored closely during the transfusion.
• The patient is observed for any signs of transfusion reactions, such as fever, chills, or urticaria.
• The rate of infusion is appropriate, and the patient’s response to the transfusion is continuously monitored.
• After the infusion, the patient is monitored for improvement in coagulation status and overall clinical condition.

✘Incorrect answer options:

Boost hemoglobin, hematocrit, and neutrophil counts. FFP is not used to increase hemoglobin, hematocrit, or neutrophil counts. Red blood cell transfusions (packed red blood cells) are used to address low hemoglobin and hematocrit, while neutrophil counts are not directly influenced by plasma transfusions.

Address issues related to platelet dysfunction. FFP is not the first line of treatment for platelet dysfunction. Platelet transfusions are specifically used to treat low platelet counts or platelet dysfunction. FFP is primarily used for clotting factor deficiencies and volume expansion.

Manage and treat thrombocytopenia. Thrombocytopenia, a condition characterized by low platelet counts, is treated with platelet transfusions rather than FFP. While FFP does contain some platelets, its primary use is to provide clotting factors and not to correct low platelet levels.

EXPLANATION

✔Correct answer:

A decrease in bleeding occurrences. The primary purpose of a platelet transfusion is to increase the platelet count in a patient, which in turn helps to reduce bleeding occurrences. Platelets play a critical role in blood clotting by aggregating at the site of a blood vessel injury and forming a plug to stop bleeding. Therefore, Nurse Jessica should monitor the patient for a decrease in bleeding occurrences as the key indicator of the effectiveness of the platelet transfusion. This can manifest as reduced mucosal bleeding (e.g., nosebleeds, gum bleeding), fewer petechiae (small red or purple spots on the skin), and a decrease in any other forms of bleeding the patient might have been experiencing.

Platelets are essential for hemostasis, the process by which the body stops bleeding. In patients with thrombocytopenia (low platelet count) or platelet dysfunction, the body’s ability to form clots is impaired, leading to an increased risk of spontaneous bleeding or prolonged bleeding following injury. A successful platelet transfusion raises the platelet count, thereby improving clot formation and reducing the risk of bleeding.

Think of platelets as sandbags used to stop a flood. If there aren’t enough sandbags (platelets), water (blood) leaks through. Adding more sandbags reduces the flooding. Similarly, after a platelet transfusion, you should see less "flooding" (bleeding) if the transfusion is effective.

In addition to monitoring for decreased bleeding, Nurse Jessica should:

• Check the patient’s post-transfusion platelet count to confirm an increase.
• Monitor vital signs and observe for any signs of transfusion reactions during and after the transfusion.
• Document any changes in the patient’s condition, including any reductions in bleeding symptoms.
• Educate the patient about signs of bleeding and when to report these symptoms.
• Ensure that the patient’s bleeding risk is reassessed regularly, especially if the patient is at ongoing risk for thrombocytopenia.

✘Incorrect answer options:

A reduction in the frequency of febrile episodes. Febrile episodes are more commonly related to infections or immune reactions and are not directly impacted by platelet transfusions. A reduction in fevers would not be a primary indicator of the effectiveness of a platelet transfusion.

A higher hematocrit level. Hematocrit levels reflect the proportion of red blood cells in the blood and are not influenced by platelet transfusions. Hematocrit would increase after a red blood cell transfusion, not a platelet transfusion.

An elevated hemoglobin level. Hemoglobin is a protein in red blood cells that carries oxygen, and its level is not directly affected by platelet transfusions. A rise in hemoglobin would indicate the success of a red blood cell transfusion, not a platelet transfusion.

EXPLANATION

✔Correct answer:

Blood warmer. When administering multiple blood transfusions, particularly in a patient who has experienced severe blood loss, using a blood warmer is essential to reduce the risk of cardiac dysrhythmias. Blood stored for transfusion is kept at a cold temperature (usually around 1-6°C), and infusing large amounts of cold blood rapidly can lead to hypothermia. Hypothermia is a significant risk factor for cardiac dysrhythmias, as it can impair the electrical activity of the heart, leading to arrhythmias, including bradycardia and ventricular fibrillation. By using a blood warmer, the blood is brought to a temperature closer to the patient’s body temperature before infusion, which helps prevent a drop in core body temperature and reduces the risk of dysrhythmias.

Hypothermia affects cardiac function by slowing down the heart rate (bradycardia) and increasing the risk of life-threatening arrhythmias. The cold temperature can alter the myocardium's conduction system, leading to disturbances in the electrical impulses that coordinate heartbeats. This is particularly dangerous in patients who are already hemodynamically unstable due to severe blood loss. A blood warmer ensures that the infused blood does not exacerbate the risk of hypothermia-induced dysrhythmias.

Imagine pouring cold water into a car's engine on a freezing day. Just as this could cause the engine to malfunction due to the sudden drop in temperature, infusing cold blood into the body can cause the heart to "malfunction" by disrupting its normal rhythm.

When preparing for multiple transfusions, Nurse Rodriguez should ensure the following:

• Check the functionality of the blood warmer and set it to the appropriate temperature range (usually between 37-40°C).
• Monitor the patient’s core body temperature throughout the transfusion process to detect any signs of hypothermia.
• Regularly assess the patient’s heart rate and rhythm to identify any early signs of dysrhythmias.
• Ensure that the blood is warmed uniformly to avoid "hot spots" that could damage blood components.
• Have emergency equipment and medications available in case of an adverse reaction or if dysrhythmias occur despite precautions.

✘Incorrect answer options:

Cardiac monitor. While a cardiac monitor is important for detecting dysrhythmias once they occur, it does not prevent them. The blood warmer plays a direct role in reducing the risk of dysrhythmias by maintaining normothermia during transfusions.

ECG machine. An ECG machine is useful for diagnosing and monitoring cardiac dysrhythmias, but like the cardiac monitor, it does not prevent these arrhythmias. It’s used for more detailed analysis of heart rhythm and electrical activity, typically after a dysrhythmia is suspected or detected.

Infusion pump. An infusion pump controls the rate of transfusion, which is important for managing fluid overload and ensuring accurate delivery of blood products. However, it does not specifically address the risk of hypothermia-induced dysrhythmias.

EXPLANATION

✔Correct answer:

Hold off on starting the blood transfusion and notify the physician.  Nurse Ellen should hold off on starting the blood transfusion and notify the physician. A temperature of 100.8°F is elevated and could be an indicator of an underlying infection or an early sign of a transfusion reaction if a fever develops further during the transfusion. Transfusing blood to a patient who already has a fever increases the risk of misinterpreting a potential transfusion reaction, as fever is a common early symptom of such reactions. Therefore, it’s crucial to consult the physician before proceeding, as they may want to investigate the cause of the fever or delay the transfusion until the patient's condition is better understood or stabilized.

Fever prior to a transfusion can complicate the clinical picture if a transfusion reaction occurs because many types of reactions, such as febrile non-hemolytic transfusion reactions, also present with fever. Additionally, an existing infection or fever could be exacerbated by the transfusion, leading to further complications. By notifying the physician, Nurse Ellen ensures that the patient receives appropriate care, and any risks associated with proceeding with the transfusion are carefully weighed.

If you notice smoke coming from an appliance before turning it on, you’d likely pause and check it out before proceeding. Similarly, when a patient has a fever before a transfusion, it’s essential to pause and notify the physician to prevent potential complications.

After holding off on the transfusion and notifying the physician, Nurse Ellen should:

• Document the patient’s temperature and any other symptoms observed.
• Follow the physician’s orders, which may include further assessment, administration of antipyretics, or postponement of the transfusion.
• Reassess the patient’s vital signs regularly to monitor any changes in their condition.
• Prepare to administer the transfusion once the physician has cleared it and the patient’s temperature has been addressed.
• Educate the patient on the importance of reporting any symptoms like chills, discomfort, or changes in their condition before and during the transfusion.

✘Incorrect answer options:

Administer an antipyretic and start the transfusion. Administering an antipyretic might mask a fever that could indicate a transfusion reaction. The priority is to determine the cause of the fever before proceeding, not to treat it symptomatically without addressing the underlying issue.

Go ahead with the transfusion as planned. Proceeding with the transfusion without investigating the elevated temperature could increase the risk of complications, such as exacerbating an underlying infection or mismanaging a transfusion reaction.

Give an antihistamine and proceed with the transfusion. Antihistamines are generally used to prevent allergic reactions, not to address fever. Administering an antihistamine would not resolve the issue of the elevated temperature and is not appropriate in this scenario.

EXPLANATION

✔Correct answer:

0.9% sodium chloride. When administering packed red blood cells (PRBCs), Nurse Alvarez should ensure that 0.9% sodium chloride (normal saline) is available to hang with the blood product. Normal saline is the only intravenous (IV) solution compatible with blood products. It is isotonic and does not cause hemolysis of red blood cells, ensuring that the transfusion is safe and effective. Normal saline is used to prime the IV line before the transfusion and to flush the line afterward. It can also be used to help maintain the patency of the IV line during the transfusion process.

Administering blood products with incompatible IV solutions can cause red blood cell lysis (destruction of red blood cells), which may lead to serious complications such as acute hemolytic reactions. Solutions that contain dextrose or calcium, like the other options listed, can cause the red blood cells to clump or lyse, which can be life-threatening for the patient. Using 0.9% sodium chloride avoids these risks because it does not interfere with the integrity of the red blood cells.

Think of 0.9% sodium chloride as the "perfect match" for blood transfusions—just like you wouldn’t mix oil with water, you wouldn’t want to mix blood with anything other than normal saline, because it keeps the blood stable and safe to transfuse.

Before administering the transfusion, Nurse Alvarez should:

• Prime the IV tubing with 0.9% sodium chloride to prevent the blood from coming into contact with any incompatible fluids.
• Use a Y-type blood administration set with a separate line for normal saline, allowing for quick flushing if needed.
• Monitor the patient closely for any signs of a transfusion reaction, particularly during the first 15 minutes of the transfusion.
• Ensure that the blood transfusion is completed within the recommended time frame (usually within 4 hours) to reduce the risk of bacterial growth or other complications.
• Document the entire process, including the use of normal saline and the patient’s response to the transfusion.

✘Incorrect answer options:

5% dextrose in 0.9% sodium chloride. Dextrose-containing solutions are not compatible with blood products because they can cause hemolysis of the red blood cells, leading to serious complications.

Balanced Multiple Maintenance Solution with 5% Dextrose. This solution, which contains dextrose and electrolytes, is also incompatible with blood products due to the risk of hemolysis and potential interactions with blood components.

5% dextrose in 0.45% sodium chloride. Similar to the other dextrose-containing solutions, this is not suitable for use with blood transfusions because the dextrose can cause red blood cell destruction.

EXPLANATION

✔Correct answer:

Septicemia. Nurse Daniels should suspect septicemia in this situation. Septicemia, or sepsis, is a life-threatening condition that occurs when bacteria or their toxins enter the bloodstream, often through contaminated blood products. The symptoms described—nausea, vomiting, hypotension (drop in blood pressure), and a rising temperature—are classic signs of septicemia. These symptoms can develop rapidly during or shortly after the transfusion of contaminated blood products. The combination of gastrointestinal symptoms (nausea and vomiting), a drop in blood pressure, and a fever strongly suggests that the patient may be experiencing septicemia as a result of receiving contaminated packed red blood cells (PRBCs).

Septicemia can occur if bacteria are introduced into the patient’s bloodstream through contaminated blood products. This can lead to a systemic inflammatory response, which causes vasodilation (leading to hypotension), fever, and other symptoms such as nausea and vomiting. If not promptly recognized and treated, septicemia can progress to septic shock, a potentially fatal condition characterized by severe hypotension, multiple organ dysfunction, and widespread tissue damage.

Think of septicemia like food poisoning from contaminated food. Just as contaminated food can cause rapid illness with symptoms like nausea, vomiting, and fever, contaminated blood can cause septicemia with similar, potentially life-threatening symptoms.

If septicemia is suspected, Nurse Daniels should:

• Stop the transfusion immediately and disconnect the IV line, ensuring the blood product and tubing are saved for testing.
• Notify the physician and prepare for possible orders to start antibiotics, fluids, and other supportive care.
• Monitor the patient’s vital signs closely, especially blood pressure, heart rate, and temperature, and be prepared to manage septic shock if it develops.
• Send blood cultures and the blood product to the laboratory for testing to confirm contamination and identify the causative organism.
• Document the patient’s symptoms, the actions taken, and the patient’s response to interventions in the medical record.

✘Incorrect answer options:

Circulatory overload. Circulatory overload is typically associated with symptoms such as dyspnea, pulmonary edema, and hypertension rather than nausea, vomiting, hypotension, and fever.

A delayed transfusion reaction. Delayed transfusion reactions occur days to weeks after the transfusion and typically present with symptoms such as jaundice, anemia, and a mild fever, rather than acute symptoms during the transfusion.

Hypocalcemia. Hypocalcemia can occur during large-volume transfusions due to the citrate used as an anticoagulant in stored blood. However, it usually presents with symptoms such as muscle cramps, tingling, or cardiac arrhythmias, not the systemic symptoms described here.

EXPLANATION

✔Correct answer:

Administer normal saline at a slow, keep-vein-open rate. After stopping the blood transfusion, Nurse Kelly should administer normal saline at a slow, keep-vein-open (KVO) rate using new IV tubing. This ensures that the IV line remains patent for the administration of any necessary medications or fluids while preventing further infusion of the blood product that caused the reaction. Administering normal saline helps maintain the patient's venous access, which is crucial if emergency drugs need to be administered quickly.

Stopping the transfusion is the first step in managing a transfusion reaction, but it's also important to keep the IV line open with normal saline. The use of new tubing ensures that no residual blood in the line is infused into the patient, which could exacerbate the reaction. Normal saline is isotonic and does not interact with the patient's blood in a harmful way, making it the safest fluid to use in this situation.

Imagine you've discovered a leak in your house. You would first turn off the water supply (stop the transfusion), but you wouldn’t dismantle the entire plumbing system. Instead, you'd keep a controlled flow of water running (normal saline at KVO rate) to ensure the system is functional for any necessary repairs.

After initiating the normal saline infusion, Nurse Kelly should:

• Monitor the patient’s vital signs closely and observe for any further symptoms of the transfusion reaction.
• Notify the physician immediately and prepare to administer any prescribed medications, such as antihistamines, corticosteroids, or epinephrine, depending on the severity of the reaction.
• Document the reaction, the interventions performed, and the patient’s response.
• Retain the blood product and tubing for return to the blood bank for investigation of the reaction.

✘Incorrect answer options:

Start an infusion of 5% dextrose in water. Dextrose solutions are not compatible with blood products because they can cause hemolysis of red blood cells. This solution should not be used after a transfusion reaction.

Disconnect the IV line completely. Disconnecting the IV line would eliminate the venous access needed for administering emergency medications or fluids. It’s crucial to keep the line patent with normal saline.

Rapidly infuse 200 ml of normal saline. Rapid infusion of fluids is not recommended immediately after a transfusion reaction unless specifically ordered and required to stabilize the patient. A slow KVO rate is preferred to maintain venous access without causing fluid overload or further stress on the patient’s cardiovascular system.