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Text Mode – Text version of the exam 1. Which nursing intervention takes highest priority when caring for a newly admitted client who’s receiving a blood transfusion? 2. Nurse Paulo has received a blood unit from the blood bank and has rechecked the blood bag properly with nurse Edward. Prior the facilitation of the blood transfusion, nurse Paulo priority check which of the following? 3. A client is brought to the emergency department having experienced blood loss due to a deep puncture wound. A 3 unit Fresh-frozen plasma (FFP) is ordered. The nurse determines that the reason behind this order is to: 4. Nurse Amanda is caring for a client with severe blood loss who is prescribed with multiple transfusion of blood. Nurse Amanda obtains which most essential piece of equipment to prevent the risk of cardiac dysrhythmias? 5. A client is receiving a first-time blood transfusion of packed RBC. How long should the nurse stay and monitor the client to ensure a transfusion reaction will not happen? 6. Nurse Rick is administering a 2 unit packed RBC’s on a client with a low hemoglobin. The nurse will prepare which of the following in order to transfuse the blood? 7. To verify the age of blood cells in a blood, the nurse will check which of the following? 8. A client has an order to receive a one unit of packed RBC’s. The nurse make sure which of the following intravenous solutions to hang with the blood product at the client’s bedside? 9. Nurse Jay is caring for a client with an ongoing transfusion of packed RBC’s when suddenly the client is having difficulty of breathing, skin is flushed and having chills. Which action should nurse Jay take first? 10. After terminating the transfusion during a reaction, which action should the nurse immediately be taken next? 11. A client is receiving a platelet transfusion. The nurse determines that the client is gaining from this therapy if the client exhibits which of the following? 12. Nurse Daniel is caring for a client receiving a transfusion of packed red blood cells (PRBCs). The client started to vomit and to be nauseous. Client’s blood pressure is 95/40 mm Hg from a baseline of 110/70 mm Hg. The client’s temperature is 100.5°F orally from a baseline of 99.5°F orally. The nurse understand that the client may be experiencing which of the following? 13. Packed red blood cells have been prescribed for a client with low hemoglobin and hematocrit levels. The nurse takes the client’s temperature before hanging the blood transfusion and records 100.8 °F. Which action should the nurse take? 14. A nurse is caring for a client requiring surgery and is ordered to have a standby blood secured if in case a blood transfusion is needed during or after the procedure. The nurse suggest to the client to do which of the following to lessen the risk of possible transfusion reaction? 15. A client is receiving transfusion of one unit of cryoprecipitate. The nurse will review which of the following laboratory studies to assess the effectiveness of the therapy? 1. Answer: D. Instructing the client to report any itching, headache, or dyspnea. This will help the nurse take immediate action incase a reaction happens during a transfusion. 2. Answer: C. Vital signs. The nurse must assess the vital signs before and 15 minutes after the procedure so that any changes during the transfusion may indicate a transfusion reaction is happening. 3. Answer: A. Provide clotting factors and volume expansion. Fresh-frozen plasma may be used to provide clotting factors or volume expansion. It is rich in clotting factors and can be thawed quickly and transfused right away. 4. Answer: B. Blood warmer. Rapid transfusion of cool blood put the client at risk for cardiac dysrhythmias. 5. Answer: A. 15 minutes. Usually, a transfusion reaction occurs within the 15 minutes of a transfusion. 6. Answer: D. Tubing with an in-line filter. The in-line filter helps ensure that any particles larger than the size of the filter are caught in the filter and are not infused with the client. 7. Answer: D. Blood expiration date. The safe storage of blood usually takes 35 days. Examining the expiration date is an important responsibility of a nurse prior hanging the blood. 8. Answer: A. 0.9% sodium chloride. 0.9% sodium chloride is a standard solution used to follow infusion of blood products. 9. Answer: D. Stop the transfusion. The client in this situation is experiencing transfusion reaction so the priority action of the nurse is to first stop the transfusion. 10. Answer: B. Run normal saline at a keep-vein-open rate. The nurse will infuse normal saline at a KVO rate to keep the patency of the IV line while waiting for further orders from the physician. 11. Answer: C. Less episodes of bleeding. Platelet transfusions may be given to prevent bleeding when the platelet count falls down. 12. Answer: D. Septicemia. Septicemia happens with the transfusion of blood that is contaminated with microorganisms. Assessment includes rapid onset of high fever and chills, hypotension, nausea, diarrhea, vomiting, and shock. 13. Answer: D. Delay hanging the blood and inform the physician. If the client has a temperature higher than 100 ° F, the unit of blood should be hung and delayed until the physician is notified and has the opportunity to give further order. 14. Answer: C. Do an autologous blood donation. A donation of the own blood is autologous. Doing this will prevent the risk of transfusion reaction. 15. Answer: C. Coagulation studies. The evaluation of an effective response of a cryoprecipitate transfusion is assessed by monitoring coagulation studies and fibrinogen levels.Practice Mode
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NCLEX Practice Exam for Blood Transfusion
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