NUR105 M4.5: ATI Skills Modules: Blood Administration (45 Minutes)
Question: A nurse is caring for a client who is about to receive a unit of packed RBCs and states, “This is my third unit of blood today. I don’t want to get some disease from all this blood.” Which of the following responses should the nurse make?NUR105 M4.5: ATI Skills Modules
Answer: B. “Donated blood is carefully screened for infectious diseases.”
Explanation: The nurse should reassure the client that donated blood undergoes rigorous screening for infectious diseases, making it safe for transfusion.
Question: A nurse is providing education to a client who has a prescription for a blood transfusion. Which of the following statements should the nurse include in the teaching?
Answer: D. “You must immediately report any symptoms like chills, nausea, or itching.”
Explanation: Clients must be informed that they should report any adverse symptoms or sensations during the transfusion, as the nurse may not be able to identify subjective symptoms.
Question: A nurse started a transfusion of packed RBCs for a client 1 hr ago. The client has suddenly developed shaking chills, muscle stiffness, and a temperature of 38.6°C (101.5°F). The client appears flushed and reports a headache and “nervousness.” The nurse should identify that the client has most likely developed which of the following types of transfusion reaction?NUR105 M4.5: ATI Skills Modules
Answer: D. Febrile nonhemolytic
Explanation: The client’s symptoms, including fever, chills, and headache, are characteristic of a febrile nonhemolytic transfusion reaction, which is the most common type of transfusion reaction.
Question: A nurse is preparing a blood transfusion for a client who has type A blood. The nurse should know that the client can safely receive blood from blood group O because:
Answer: A. Type O blood contains no A antigens.NUR105 M4.5: ATI Skills Modules
Explanation: Type O blood contains no A antigens, making it compatible with clients who have type A blood.
Question: Which of the following actions should a nurse take prior to starting a blood transfusion?
Answer: C. Ensure that informed consent has been obtained from the client.
Explanation: It is essential to ensure that the client has given informed consent before initiating a blood transfusion. Informed consent is the responsibility of the prescribing healthcare provider, and the nurse can witness the client’s signature.
Question: A nurse is caring for a client who is receiving a blood transfusion and reports itching. The nurse observes areas of urticaria on the client’s skin. Which of the following actions should the nurse take?NUR105 M4.5: ATI Skills Modules
Answer: B. Stop the blood transfusion.
Explanation: Itching and urticaria are signs of an allergic reaction to the blood transfusion. The nurse should stop the transfusion and follow facility protocol for transfusion reactions.NUR105 M4.5: ATI Skills Modules
Question: A platelet transfusion is indicated for a patient who:
Answer: B. Has thrombocytopenia.
Explanation: A platelet transfusion is typically indicated for a client with thrombocytopenia (low platelet count).
Question: A client who is anticipating a total hip replacement is considering autologous transfusion. When teaching this client about autologous transfusion, it is important to emphasize that:
Answer: A. It reduces the risk of mismatched blood.
Explanation: Autologous transfusion involves using the client’s own blood, reducing the risk of receiving mismatched blood.
Question: When administering a transfusion of packed red blood cells, it is important to:
Answer: B. Make sure the entire unit is transfused within 4 hr.
Explanation: To prevent bacterial proliferation, a unit of packed RBCs should be transfused within 4 hours.
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