Preview Extract
Chapter 23
1. What is the purpose of checking the temperature, pulse, blood pressure, and weight of a
potential blood donor?
Select all that apply.
1. Individuals with a fever are not used due to the risk of infection
2. Individuals with a high blood pressure are not permitted to donate blood.
3. Individuals with a very high pulse are not permitted to donate blood.
4. Individuals with a very low pulse rate (with the exception of highly conditioned athletes)
are not permitted to donate blood.
5. Individuals with an irregular heartbeat are not permitted to donate blood.
Answer: 1. Individuals with a fever are not used due to the risk of infection
2. Individuals with a high blood pressure are not permitted to donate blood.
3. Individuals with a very high pulse are not permitted to donate blood.
4. Individuals with a very low pulse rate (with the exception of highly conditioned athletes),
are not permitted to donate blood.
5. Individuals with an irregular heartbeat are not permitted to donate blood.
Rationale:
Individuals with a fever are not used due to the risk of infection. A fever possibly indicates
the presence of infection, which increases the risk of transmitting it to the recipient.
Individuals with a high blood pressure are not permitted to donate blood. There is too big of a
physiological risk to the donor to take the blood. Individuals with a very high pulse are not
permitted to donate blood. There is too big of a risk of altered tissue perfusion for the donor
to take the blood. Individuals with a very low pulse rate (with the exception of highly
conditioned athletes) are not permitted to donate blood. Unless the potential donor is a
seasoned athlete, there is too big of a risk of altered tissue perfusion for the donor to take the
blood. Individuals with an irregular heartbeat are not permitted to donate blood. There is too
big of a risk of altered tissue perfusion for the donor to take the blood.
2. You are interviewing a potential blood donor, and you ask the individual how much she
weighs. What is the purpose of this question?
1. National guidelines dictate that the donor’s body weight must be greater than 50 kg (110
lb) to donate 450 mL of blood.
2. The donor’s body weight determines how rapidly the blood can be taken from the donor.
3. The donor’s body weight helps determine the presence of an infection.
4. The donor’s body weight determines how long the individual must remain lying down after
the blood donation.
Answer: National guidelines dictate that the donor’s body weight must be greater than 50 kg
(110 lb) to donate 450 mL of blood.
Rationale:
Weight must be greater than 50 kg (110 lb) to donate 450 mL of blood. This is a national
guideline put forth by the American Red Cross. The donor’s weight determines how much
blood can be taken, not how fast it can be taken. There is not correlation of weight to rates of
infection. Body weight is not related to length of time needed to rest after blood donation.
3. You are the nurse interviewing a potential blood donor. You ask the client what
medications he uses (prescription, over the counter, blood thinners, recent immunization, and
illicit). What is the purpose of this question?
1. Medications can pass from blood donor to recipient in the donated blood.
2. To educate the blood donor about risks associated with illicit drug use.
3. The physician at the blood bank must be notified of all drug use in potential donors.
4. A list of medications will be placed on the bag of donated blood.
Answer: Medications can pass from blood donor to recipient in the donated blood.
Rationale:
Medications are present in the bloodstream for defined periods of time after injection;
therefore, they can be passed to the recipient in a blood transfusion. Educating the blood
donor about risks associated with illicit drug use is not the purpose of the question. Notifying
the health care provider at the blood bank of all drug use in potential donors is not a standard
procedure. Placing a list of medications on the bag of donated blood is not a standard
procedure at blood banks.
4. The client is asking why the doctor ordered only red blood cells (packed RBCs) instead of
the entire unit of whole blood. The nurse explains that:
1. It is an optimal method of transfusing only the specific component needed by the client.
2. It is the only blood that is left in the blood bank.
3. RBCs are useful for clients who are experiencing a lack of clotting factors.
4. RBCs are useful for preventing transfusion reactions.
Answer: It is an optimal method of transfusing only the specific component needed by the
client.
Rationale:
Using only the component that is needed is a safe and economical use of the blood supply.
Using the only blood that is left in the blood bank would never be the rationale for a blood
transfusion. Cryoprecipitates, plasma, and platelets are used for replacing clotting factors.
RBCs cannot prevent a transfusion reaction.
5. The nurse is caring for an 80-year-old client who is receiving a unit of whole blood. The
nurse understands that he must monitor this client for:
1. Fluid overload.
2. Infection.
3. Liver failure.
4. Thrombosis.
Answer: Fluid overload.
Rationale:
High-risk clients for fluid overload are the elderly and those individuals who already have
increased circulatory volume or who have a history of heart failure. Whole blood contains the
most volume, and therefore it has the highest risk of fluid overload. The clinical
manifestations of bacterial contamination may not occur until the transfusion is complete, or
in some instances several hours later, depending on the virulence of the infecting organism.
Liver failure is not associated with blood transfusions. Increased risk for thrombosis is not
associated with blood transfusions.
6. What are the advantages of blood component therapy as a method of transfusion?
Select all that apply.
1. It is more economical to separate blood into its component parts.
2. It is safer to use only that portion needed by the client for a specific condition or disease.
3. It conserves the blood resources, because one unit can be used for multiple recipients.
4. It decreases volume overload.
5. It reduces side effects and complications.
Answer: 1. It is more economical to separate blood into its component parts.
2. It is safer to use only that portion needed by the client for a specific condition or disease.
3. It conserves the blood resources, because one unit can be used for multiple recipients.
4. It decreases volume overload
5. It reduces side effects and complications.
Rationale:
It is more economical to separate blood into its component parts. Clients seldom require all of
the components of whole blood; therefore, blood component therapy is more appropriate and
economical. Blood is separated into its component parts, and only that portion needed by the
client for a specific condition or disease is given. It is safer to use only that portion needed by
the client for a specific condition or disease. The client receives only the needed components,
thereby decreasing volume overload and reducing side effects and complications. It conserves
the blood resources, because one unit can be used for multiple recipients. Up to six recipients
can benefit from one unit of whole blood, thereby conserving blood resources. Blood is
fractioned into component parts by either a centrifuge or a cell separator. Each component is
then processed and stored appropriately, so as to maximize longevity and cell viability. It
decreases volume overload. By giving only the needed component, the volume is decreased.
For example, giving packed RBCs instead of whole blood decreases the volume by
approximately 50%. It reduces side effects and complications. There are more side effects
associated with certain cells from the donor. By removing these cells, it decreases the side
effects and complications.
7. You are caring for a client who was admitted 14 hours ago following a motorcycle
accident. The client has received 20 units of blood due to massive hemorrhage. You
understand that you need to assess this client for:
Select all that apply.
1. Elevated blood ammonia titers.
2. Coagulation imbalances.
3. Hypocalcemia.
4. Acid–base imbalance.
5. Hyperkalemia.
Answer: 1. Elevated blood ammonia titers.
2. Coagulation imbalances.
3. Hypocalcemia.
4. Acid–base imbalance.
5. Hyperkalemia.
Rationale:
Elevated blood ammonia titers. Clients who have repeated exposure to blood products and the
preservatives used to store blood products have an increased risk of developing elevated
blood ammonia titers. Coagulation imbalances. Clients who have repeated exposure to blood
products and the preservatives used to store blood products have an increased risk of
developing coagulation imbalances. Hypocalcemia. Clients who have repeated exposure to
blood products and the preservatives used to store blood products have an increased risk of
developing hypocalcemia. Acid–base imbalance. Clients who have repeated exposure to
blood products and the preservatives used to store blood products have an increased risk of
developing acid–base imbalance. Hyperkalemia. Clients who have repeated exposure to
blood products and the preservatives used to store blood products have an increased risk of
developing hyperkalemia.
8. The nurse understands that the osmotic makeup of the blood causes fluid to be mobilized
from the interstitial space, which increases the risk for:
1. Circulatory overload.
2. Hypovolemia.
3. Infection.
4. Transfusion reaction.
Answer: Circulatory overload.
Rationale:
Circulatory overload can occur with transfusions because the increased osmotic makeup of
the blood causes fluid to be mobilized from the interstitial space, thereby increasing
intravascular volume well beyond that given during the transfusion. High-risk clients include
the elderly and those individuals who already have increased circulatory volume or who have
a history of heart failure. Hypovolemia is not a consideration because the volume is being
increased, not decreased. Infections do not manifest themselves until after the completion of
the transfusion and are not related to the osmolality of the blood. Transfusion reactions are
not associated with the osmotic makeup of the blood.
9. The nurse is caring for a client who suddenly developed severe respiratory distress 2 hours
after a blood transfusion. The health provider is notified and a diagnosis of transfusionrelated acute lung injury (TRALI) is made. The nurse understands that this client may:
1. Never have another transfusion from the same donor.
2. Never have another transfusion again from any donor.
3. Have transfusions again because the donor did not precipitate this event.
4. Have family members who cannot ever have transfusions.
Answer: Never have another transfusion from the same donor.
Rationale:
The exact cause of this complication is not fully understood. One prevailing theory is that
TRALI is thought to be caused by the presence of granulocyte antibodies and biologically
active lipids in the donor plasma that the recipient reacts to. If antibodies are present in the
donor’s plasma, they stimulate the WBCs in the recipient’s blood. Aggregates of WBCs form
and occlude the microvasculature of the lungs. All plasma-containing blood components,
including RBCs, platelets, FFP, and cryoprecipitates, can be a cause of TRALI. Once TRALI
has occurred, the recipient should not receive any more transfusions from the same donor.
Transfusion from other donors poses no increased risk.
It is acceptable to have another transfusion from another donor. Family members should be
informed, but it is not an indication for them to not have transfusions
10. The policy and procedure for blood administration calls for giving no more than 30 mLs
in the first 15 minutes. To give that much through tubing with 10 gtts/mL, what would the
drip rate be?
1. 20 gtts/min
2. 5 gtts/min
3. 12 gtts/min
4. 60 gtts/min
Answer: 20 gtts/min
Rationale:
If the client is to receive 30 mLs in 15 minutes, that would be 2 mLs per minute. At 10 gtts
per mL, that would be 20 gtts per minute. The other amounts are incorrectly calculated.
11. Which statement made by the client would indicate further teaching is necessary about
blood transfusions?
1. There is no risk of a disease being transmitted through the transfusion of someone else’s
blood.
2. There is a period of time when HIV-contaminated blood will test negative.
3. There is still some risk of contracting hepatitis B through a blood transfusion.
4. There is still some risk of contracting hepatitis C through a blood transfusion.
Answer: There is no risk of a disease being transmitted through the transfusion of someone
else’s blood.
Rationale:
It is not true that there is no risk of disease transmission from a blood transfusion. This client
needs further education. The other statements are correct and do not require further teaching.
12. The nurse is caring for a client who was admitted 5 hours ago after sustaining multiple
gunshot wounds to the abdomen. The client has had 8 units of blood. The blood bank notified
the nurse that it was short of blood. The nurse understands that the client can receive any type
of blood if she has ____ blood type.
1. AB
2. A
3. B
4. O
Answer: AB
Rationale:
The person with blood type A has B antibodies; someone with type B has A antibodies;
someone with type AB has no antibodies; and a person who has type O blood has both
antibodies. Therefore, the person with type AB blood can receive any type of blood in an
emergency situation and is referred to as the universal recipient. A person with the O blood
type is considered a universal donor in an emergency situation.
13. A unit of packed red blood cells was ordered for a client. Twenty minutes after the blood
began infusing, the client developed dyspnea, chest pain, bloody urine, and a decrease in
blood pressure. This type of transfusion reaction is:
1. Acute hemolytic reaction.
2. Allergic reaction.
3. Delayed hemolytic reaction.
4. Febrile nonhemolytic reaction.
Answer: Acute hemolytic reaction.
Rationale:
Bloody urine and decreased urine output, petechiae, jaundice, decreased blood pressure, chest
tightness, low back pain, nausea, anxiety, dyspnea, hypotension, bronchospasm,
hemoglobinemia, acute renal failure, shock, cardiac arrest, and death are symptoms that
typically occur within the first 15 minutes of the transfusion with an acute hemolytic reaction.
Allergic reactions are manifested by itching, hives, flushing, and chills. Delayed hemolytic
reactions are manifested by fever, anemia, increased bilirubin level, decreased or absent
haptoglobin, and jaundice. Febrile nonhemolytic reactions are manifested by increased pulse
rate, temperature > 1oC, chills, headache, nausea and vomiting, anxiety, flushing, back pain,
and muscle aches.
14. Which of the following cause an acute hemolytic transfusion reaction?
Select all that apply.
1. Nurse’s error when checking the blood
2. ABO incompatibility of the donor and recipient
3. WBC incompatibility
4. Recipient’s sensitivity to foreign plasma proteins
5. Contaminated blood
Answer: 1. Nurse’s error when checking the blood
2. ABO incompatibility of the donor and recipient
Rationale:
Nurse’s error when checking the blood. Acute hemolytic reactions may be due to a mistake in
labeling by the laboratory or blood bank or nursing error. ABO incompatibility of the blood
and recipient. This is the physiological reason for the transfusion reaction. WBC
incompatibility. WBC incompatibility causes febrile nonhemolytic reactions. Recipient’s
sensitivity to foreign plasma proteins. Recipient sensitivity to foreign plasma proteins causes
allergic reactions. Contaminated blood. Contaminated blood causes infections, not
transfusion reactions.
15. Why is the nursing diagnosis of Risk of Injury related to blood transfusions?
Select all that apply.
1. Risk of transfusion reactions
2. Risk of disease transmission
3. Risk of fluid overload
4. Risk of transfusion-related lung injury
5. Risk of iron overload
Answer: 1. Risk of transfusion reactions
2. Risk of disease transmission
3. Risk of fluid overload
4. Risk of transfusion-related lung injury
5. Risk of iron overload
Rationale:
Risk of transfusion reactions. When a client is receiving a blood transfusion, there are risks
involved, including risk of transfusion reactions. That is why Risk for Injury is an appropriate
nursing diagnosis. Risk of disease transmission. When a client is receiving a blood
transfusion, there are risks involved, including risk of disease transmission. That is why Risk
for Injury is an appropriate nursing diagnosis. Risk of fluid overload. When a client is
receiving a blood transfusion, there are risks involved, including risk of fluid overload. That
is why Risk for Injury is an appropriate nursing diagnosis. Risk of transfusion-related lung
injury. When a client is receiving a blood transfusion, there are risks involved, including risk
of transfusion-related lung injury. That is why Risk for Injury is an appropriate nursing
diagnosis. Risk of iron overload. When a client is receiving a blood transfusion, there are
risks involved, including risk of iron overload. That is why Risk for Injury is an appropriate
nursing diagnosis.
Test Bank for Timby's Introductory Medical-Surgical Nursing
Loretta A Donnelly-Moreno, Brigitte Moseley
9781975172237, 9781975172268
