NUR105 M4.6: ATI Skills Modules: Virtual Scenarios – Blood Transfusion
Question: At the beginning of your shift or client interaction, which of the following should you complete? Select All That Apply.
Verify client identity using name and birthdate
Introduce self
Perform hand hygiene
Provide privacy
Answer: All options should be selected.NUR105 M4.6: ATI Skills Modules
Explanation: At the beginning of your shift or when interacting with a client, you should verify the client’s identity, introduce yourself, perform hand hygiene, and provide privacy to ensure safe and respectful care.
Question: Which information from the client’s chart is important to consider before obtaining the blood product from the blood bank?NUR105 M4.6: ATI Skills Modules
Blood type and crossmatch date and time
I&O for the past 24 hours
Current Hgb and Hct results
Answer: Blood type and crossmatch date and time.
Explanation: It is crucial to consider the blood type and crossmatch date and time to ensure that you are administering the correct blood product to the client.NUR105 M4.6: ATI Skills Modules
Question: When inspecting Kathy’s unit of packed RBCs, which of the following findings should you indicate as an indication of contamination or hemolysis. Select All That Apply.NUR105 M4.6: ATI Skills Modules
Purple color
Cloudiness
White Particulate Matter
Clumping
Answer: All options should be selected.
Explanation: Any of these findings, such as a purple color, cloudiness, white particulate matter, or clumping, can indicate contamination or hemolysis, and the unit should not be used.
Question: What IV tubing should I select?
Answer: The tubing with 2 spikes
Explanation: When administering blood, it is essential to use tubing with two spikes to ensure safe and efficient transfusion.
Question: Which of the following solutions should you use to transfuse packed RBCs?
Answer: 0.9% Sodium Chloride
Explanation: 0.9% Sodium Chloride (normal saline) is the appropriate solution for transfusing packed RBCs. It is compatible with blood products.
Question: Is it okay to give me O- blood?NUR105 M4.6: ATI Skills Modules
Answer: Yes, it is okay for you to receive this type of blood.
Explanation: O- blood is considered the universal donor blood type, and it can be safely transfused to individuals with other blood types.
Question: Besides scanning the barcodes, what else will I need to check?
What is your name and DOB?
Check the arm bands
Read the label on the blood bag
Review the provider’s prescription
Finished verifying info.
Answer: All options should be checked.NUR105 M4.6: ATI Skills Modules
Explanation: Apart from scanning barcodes, it is essential to verify the client’s name, date of birth, check the arm bands, read the label on the blood bag, and review the provider’s prescription to ensure the correct blood product is administered.
Question: What actions are required before preparing blood supplies?
Answer: Sanitize hands and put on clean gloves.
Explanation: Hand hygiene and wearing clean gloves are essential steps to maintain aseptic technique when preparing blood supplies.
Question: What is the first step to prepare the tubing?
Answer: Close all clamps.
Explanation: Closing all clamps on the tubing is the initial step in preparing the tubing for blood administration.
Question: What is step 2?
Answer: Spike the fluid bag.
Explanation: After closing the clamps, the next step is to spike the fluid bag.
Question: What is step 3?
Answer: Open clamp B.
Explanation: After spiking the fluid bag, you should open clamp B to allow the flow of fluids.
Question: Determine the rate in mL/hr to initiate the packed RBC transfusion to administer 300mL at an initial rate of 2mL/min.
Answer: 120 mL/hr
Explanation: To administer 300 mL over a specific time, you can calculate the rate by dividing the total volume by the time in hours. In this case, 300 mL divided by 2 mL/min equals 150 minutes, which is equivalent to 2.5 hours. So, the rate is 300 mL/2.5 hours, which is 120 mL/hr.
Question: Let me know if you experience
Facial flushing or itching
Answer: The question is asking the client to inform the nurse if they experience facial flushing or itching, which are potential signs of a transfusion reaction.
Question: When will you be checking my vital signs again?
Answer: 15 minutes
Explanation: Vital signs are typically monitored every 15 minutes during a blood transfusion to detect any early signs of a reaction.
Question: What should I do first?
Answer: Stop the blood transfusion.
Explanation: If a transfusion reaction is suspected, the first action is to stop the blood transfusion to prevent further administration of the blood product.
Question: What should I do next?
Answer: Connect new tubing and infuse 0.9% Sodium chloride
Explanation: After stopping the blood transfusion, it’s important to replace the tubing and initiate an infusion of 0.9% Sodium chloride to maintain intravenous access and ensure the client’s well-being.
Question: What might be happening here?
Answer: You’re showing symptoms of an acute hemolytic transfusion reaction.
Explanation: The client is exhibiting symptoms indicative of an acute hemolytic transfusion reaction, which is a severe type of transfusion reaction.
Question: Which of the following items should you send to the lab if the client has a transfusion reaction? Select All That Apply.
Blood bag
Blood transfusion tubing
Blood sample
Urine sample
Answer: Blood bag, Blood transfusion tubing, Blood sample, Urine sample
Explanation: In the event of a transfusion reaction, it is important to send various samples and components for laboratory analysis to determine the cause of the reaction and appropriate treatment.
Question: What are you going to do to ensure that I am okay until then?
Answer: Check vital signs frequently.
Explanation: To ensure the client’s well-being after a transfusion reaction, frequent monitoring of vital signs is necessary.
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