1 Which nursing intervention takes highest priority when

1. Which nursing intervention takes highest priority when caring for a newly admitted patient who’s receiving a blood transfusion? A. Warming the blood prior transfusion. B. Informing the patient that the transfusion usually takes 4 to 6 hours. C. Documenting blood administration in the patient chart. D. Instructing the patient to report any itching, chest pain, or dyspnea. 1. The Correct Answer is : D. Instructing the patient to report any itching, headache, or dyspnea. This will help the nurse take immediate action incase a reaction happens during a transfusion.

2. Nurse Paulo has received a blood unit from the blood bank and has rechecked the blood bag properly with nurse Edward. Prior to the blood transfusion, nurse Paulo should first check which of the following? A. Intake and output. B. NPO standing order. C. Vital signs. D. Skin turgor. 2. The Correct Answer is : 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. A patient 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: A. Provide clotting factors and volume expansion. B. Increase hemoglobin, hematocrit, and neutrophil levels. C. Treat platelet dysfunction. D. Treat thrombocytopenia. 3. The Correct Answer is : 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. Option B is incorrect since it will not specifically increase the hemoglobin, hematocrit, and neutrophil level.

4. Nurse Amanda is caring for a patient 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? A. Cardiac monitor. B. Blood warmer. C. ECG machine. D. Infusion pump. 4. The Correct Answer is : B. Blood warmer. Rapid transfusion of cool blood put the patient at risk for cardiac dysrhythmias. Options A and C are used to assess for any blood transfusion-related complication, but they do not prevent the occurrence of cardiac dysrhythmia. Option D is not beneficial in this case since the infusion must be given rapidly.

5. A patient is receiving a first-time blood transfusion of packed RBC. How long should the nurse stay and monitor the patient to ensure a transfusion reaction will not happen? A. 15 minutes. B. 30 minutes. C. 45 minutes. D. 60 minutes. 5. The Correct Answer is : A. 15 minutes. Usually, a transfusion reaction occurs within the 15 minutes of a transfusion.

6. Nurse Rick is administering a 2 unit packed RBC’s on a patient with a low hemoglobin. The nurse will prepare which of the following in order to transfuse the blood? A. Microfusion set. B. Polyvol Pro Burette Set. C. Photofusion set. D. Tubing with an in-line filter. 6. The Correct Answer is : 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 patient. Option A is incorrect since the tubing that should be used is a macro drip. Option B is used for administration of IV medication infusion. Option C is incorrect since blood does not need any protection from light.

7. To verify the age of blood cells in a blood, the nurse will check which of the following? A. Blood type. B. Blood group. C. Blood identification number. D. Blood expiration date. 7. The Correct Answer is : 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. A patient has an order to receive one unit of packed RBC’s. The nurse make sure which of the following intravenous solutions to hang with the blood product at the patient’s bedside? A. 0. 9% sodium chloride. B. 5% dextrose in 0. 9% sodium chloride. C. Balanced Multiple Maintenance Solution with 5% Dextrose. D. 5% dextrose in 0. 45% sodium chloride. 8. The Correct Answer is : A. 0. 9% sodium chloride is a standard solution used to follow infusion of blood products. Options B, C, and D: IV solution containing dextrose in water will hemolyze red cells.

9. Nurse Jay is caring for a patient with an ongoing transfusion of packed RBC’s when suddenly the patient is having difficulty of breathing, skin is flushed and having chills. Which action should nurse Jay take first? A. Administer oxygen. B. Place the patient on droplight. C. Check the patient’s temperature. D. Stop the transfusion. 9. The Correct Answer is : D. Stop the transfusion. The patient in this situation is experiencing transfusion reaction so the priority action of the nurse is to first stop the transfusion.

10. After terminating the transfusion during a reaction, which action should the nurse immediately be taken next? A. Run a solution of 5% dextrose in water. B. Run normal saline at a keep-vein-open rate. C. Remove the IV line. D. Fast drip 200 ml normal saline. 10. The Correct Answer is : 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. Option A: IV solution containing dextrose will hemolyze the red cells. Option C: The nurse will not remove the IV line because then there would be no IV access route. Option D: Doing a fast drip will potentially lead to congestion and is not done without the

11. A patient is receiving a platelet transfusion. The nurse determines that the patient is gaining from this therapy if the patient exhibits which of the following? A. Less frequent febrile episodes. B. Increased level of hematocrit. C. Less episodes of bleeding. D. Increased level of hemoglobin. 11. The Correct Answer is : C. Less episodes of bleeding. Platelet transfusions may be given to prevent bleeding when the platelet count falls down. Option A: A decline in the febrile episode will happen after the transfusion of agranulocytes. Options B and D: An increased level of hemoglobin and hematocrit will happen after the

12. Nurse Daniel is caring for a patient receiving a transfusion of packed red blood cells (PRBCs). The patient started to vomit and to be nauseous. patient’s blood pressure is 95/40 mm Hg from a baseline of 110/70 mm Hg. The patient’s temperature is 100. 5°F orally from a baseline of 99. 5°F orally. The nurse understand that the patient may be experiencing which of the following? A. Circulatory overload. B. Delayed transfusion reaction. C. Hypocalcemia. D. Septicemia. 12. The Correct Answer is : D. 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. Option A: Circulatory overload causes hypertension, cough, dyspnea, chest pain, tachycardia, and wheezing upon auscultation. Option B: Delayed reaction can occur days to years after a transfusion. It causes, fever, rashes, mild jaundice, and oliguria or anuria. Option C: Hypocalcemia causes paresthesias, tetany, muscle cramps, hyperactive reflexes, positive Trousseau’s sign, and positive Chovstek’s sign.

13. Packed red blood cells have been prescribed for a patient with low hemoglobin and hematocrit levels. The nurse takes the patient’s temperature before hanging the blood transfusion and records 100. 8 °F. Which action should the nurse take? A. Give an antipyretic and begin the transfusion. B. Proceed with the transfusion. C. Administer an antihistamine and begin the transfusion. D. Delay hanging the blood and inform the physician. 13. The Correct Answer is : D. Delay hanging the blood and inform the physician. If the patient 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. Options A and C are incorrect since the administration of the medicine will need the physician’s prescription.

14. A nurse is caring for a patient 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 patient to do which of the following to lessen the risk of possible transfusion reaction? A. Request that any donated blood be screened twice by the blood bank. B. Take iron supplement prior the surgery and eat green leafy vegetables. C. Do an autologous blood donation. D. Have a family member donate their own blood. 14. The Correct Answer is : C. Do an autologous blood donation. A donation of the own blood is autologous. Doing this will prevent the risk of transfusion reaction.

15. A patient is receiving transfusion of one unit of cryoprecipitate. The nurse will review which of the following laboratory studies to assess the effectiveness of therapy? A. Serum electrolytes. B. White blood cell count. C. Coagulation studies. D. Hematocrit count. 15. The Correct Answer is : C. Coagulation studies. The evaluation of an effective response of a cryoprecipitate transfusion is assessed by monitoring coagulation studies and fibrinogen levels.

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8. A patient 8. The correct answer is : : (B) In the

8. A patient 8. The correct answer is : : (B) In the

8. A patient 8. The correct answer is : : (B) In the

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MCQs for Nursing Students 17 NCLEX PN EXAMINATION ON BLOOD TRANSFUSION