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Nursing Assessment of Blood Transfusion Reactions

- The nurse should assess the patient for any signs and symptoms of transfusion reactions during and after blood transfusion. The assessment should include:

  • Vital signs: Monitor the patient’s blood pressure, pulse, respiratory rate, temperature, and oxygen saturation at least every 15 minutes for the first hour and then every 30 minutes until the end of the transfusion. Compare them with the baseline values and report any significant changes to the physician. A rise or fall in blood pressure, pulse, or temperature may indicate a transfusion reaction.
  • Skin: Observe the patient’s skin color, temperature, moisture, and integrity. Look for any signs of rash, urticaria, pruritus, flushing, angioedema, cyanosis, or pallor. These may indicate an allergic or hemolytic reaction.
  • Respiratory: Auscultate the patient’s lung sounds and look for any signs of dyspnea, cough, wheeze, crackles, or stridor. These may indicate TRALI, TACO, or anaphylaxis.
  • Cardiovascular: Auscultate the patient’s heart sounds and look for any signs of chest pain, palpitations, arrhythmias, or murmurs. These may indicate myocardial ischemia or infarction due to hemolysis or hypotension.
  • Renal: Measure the patient’s urine output and look for any signs of hemoglobinuria, oliguria, anuria, or renal failure. These may indicate acute tubular necrosis due to hemolysis or hypotension.
  • Neurologic: Assess the patient’s level of consciousness, orientation, memory, speech, and motor and sensory functions. Look for any signs of headache, dizziness, confusion, agitation, seizures, or coma. These may indicate cerebral hypoxia or ischemia due to hemolysis or hypotension.
  • Gastrointestinal: Assess the patient’s abdominal pain, nausea, vomiting, diarrhea, or constipation. These may indicate sepsis or graft-versus-host disease due to bacterial contamination or immunologic reaction.
  • Hematologic: Obtain post-transfusion laboratory tests as ordered by the physician to evaluate the effectiveness and safety of transfusion. These may include hemoglobin, hematocrit, platelet count, coagulation studies, electrolytes, bilirubin, and urine analysis

Questions on Nursing Assessment of Blood Transfusion Reactions

Correct Answer is B

Explanation

"I have a stable cardiovascular disease." Rationale: The presence of stable cardiovascular disease is not directly related to the need for a blood transfusion based on a hemoglobin level of 7 g/dL. The decision to transfuse should primarily be based on the patient's hemoglobin level and symptoms.

Correct Answer is C

Explanation

Platelets. Rationale: Platelets are involved in the clotting process, but they do not contain significant amounts of fibrinogen. Platelets are used to treat conditions where there is a deficiency in platelet count or function, not to increase fibrinogen levels.

Correct Answer is ["A","B","E"]

Explanation

Document the procedure accurately. Rationale: Accurate documentation is essential for maintaining a complete record of the transfusion process. It includes documenting the patient's identification, vital signs, the type and volume of blood product administered, any adverse reactions, and the patient's response to the transfusion. This documentation serves as a legal and clinical record of the procedure.

Correct Answer is D

Explanation

Platelets. Rationale: Platelets are the correct choice for a patient with thrombocytopenia. Platelet transfusion provides a concentrated dose of platelets, which can help increase the patient's platelet count and improve clotting ability. It directly addresses the underlying issue in thrombocytopenia, making it the most suitable option.

Correct Answer is A

Explanation

Platelets. Rationale: Platelets are responsible for clot formation and are primarily used to treat thrombocytopenia or clotting disorders. They do not address the anemia component of the patient's condition and are not typically considered an alternative to blood transfusion for anemic patients with ongoing bleeding. ABO and Rh Blood Group Systems:

Correct Answer is B

Explanation

"I can receive blood from donors with blood types A-, A+, or O-." Rationale: This statement is incorrect because it suggests that an A- individual can receive blood from A+ donors. As mentioned earlier, the Rh factor must be compatible, and A- individuals should not receive Rh-positive blood.

Correct Answer is D

Explanation

This choice is correct. Individuals with blood type AB+ can safely receive blood from donors with blood types AB+, A+, A-, or B+. The rationale behind this is that AB+ individuals have both A and B antigens on their red blood cells and do not have anti-A or anti-B antibodies in their plasma. Therefore, they can receive blood with ABO and RhD compatibility.

Correct Answer is ["A","B","D","E"]

Explanation

O- blood is compatible with blood type O- because it does not contain A, B, or RhD antigens, which could be targeted by antibodies in the recipient.

Correct Answer is C

Explanation

AB- blood can be safely transfused to a client with blood type B+ since B+ individuals do not have anti-A or anti-B antibodies. However, the reverse is not true. A client with blood type B+ should not receive AB- blood because AB- blood contains both A and B antigens, which can react with the antibodies present in the recipient's plasma.

Correct Answer is B

Explanation

<p>B+ blood type contains B antigens and the Rh antigen (positive) Blood type O+ lacks B antigens but does have the Rh antigen. Therefore, B+ blood is not compatible with O+ blood due to ABO incompatibility.</p>

Correct Answer is C

Explanation

Administering the transfusion as quickly as possible is not appropriate and can be dangerous. Transfusions should be administered at a controlled and appropriate rate to monitor for any adverse reactions. Rushing the transfusion can increase the risk of complications.

Correct Answer is A

Explanation

Using any available intravenous line for the transfusion may not be appropriate, especially if the line is already in use for other medications or fluids. The nurse should select a dedicated line for the transfusion to minimize the risk of contamination or complications.

Correct Answer is ["A","C"]

Explanation

Decreased oxygen saturation is not a typical sign of delayed transfusion reactions. It is important to monitor oxygen saturation during a blood transfusion, but this is more relevant to immediate transfusion reactions, such as transfusion-related acute lung injury (TRALI)

Correct Answer is A

Explanation

Educating the patient about the procedure is important but should be done before the transfusion, not immediately after. Immediate post-transfusion care involves monitoring the patient and obtaining necessary laboratory tests.

Correct Answer is C

Explanation

<p>Using a 24-gauge IV catheter for a blood transfusion may not be suitable for all patients. The size of the catheter should be appropriate for the type of blood product being transfused and the patient&#39;s vein size. A larger catheter may be necessary for blood products with higher viscosity.</p>

Transfusion-associated circulatory overload (TACO) typically presents with symptoms related to volume overload, such as pulmonary edema, hypertension, and tachycardia. It does not typically manifest with fever, chills, back pain, chest pain, dyspnea, or jaundice.

An allergic reaction, also known as a hypersensitivity reaction, can manifest with symptoms like urticaria (hives), pruritus (itching), and flushing. These symptoms are indicative of an allergic response to components in the blood product, such as plasma proteins or allergens.

Bacterial contamination of blood products can indeed result in sepsis. This is a severe and life-threatening complication of transfusion, making it important to ensure the safety of blood products and proper handling to prevent contamination.

Febrile nonhemolytic reactions are characterized by fever and chills and do not typically manifest as dyspnea, orthopnea, tachypnea, or crackles on lung auscultation.

<p>Allergic reactions to blood transfusions typically present with symptoms like itching, hives, and flushing, but not with gastrointestinal symptoms like abdominal pain, nausea, vomiting, and diarrhea.</p>

Transfusion-related immunomodulation (TRIM) is a theoretical concept and not a recognized clinical entity. It is not associated with the specific symptoms mentioned in the question.

Post-transfusion purpura is a rare condition that occurs 5 to 12 days after a transfusion and is characterized by sudden severe thrombocytopenia (low platelet count) and bleeding, often in the form of purpura. It does not typically present with fever, rash, and pancytopenia, so it is not the best ch

Disposing of used blood products and materials according to hospital policy is crucial to prevent potential contamination and reduce the risk of infection transmission. Proper disposal procedures are a part of overall transfusion safety protocols.

Viral infections can be a complication of blood transfusions, but they do not typically present with these specific bleeding symptoms within 7 days after the transfusion. Viral infections may cause a broader range of symptoms and have a longer incubation period.

<p>Monitoring the patient&#39;s condition only after the transfusion is not sufficient to ensure safety. Continuous monitoring during the transfusion is necessary to detect and respond to any adverse reactions promptly.</p>

Hemostatic agents are not a substitute for blood transfusion. They are used to control bleeding but do not address anemia or increase hemoglobin levels.

Iron therapy is generally used to treat iron deficiency anemia, but it may not be the most effective option for anemia related to chronic kidney disease, as it does not address the underlying cause. Erythropoietin therapy is a more targeted approach.

Oxygen therapy is not a volume expander. While it can increase the oxygen-carrying capacity of the blood by providing supplemental oxygen, it does not increase blood volume or circulation and is not used for that purpose.

Iron therapy is used to treat iron-deficiency anemia and increase hemoglobin levels. It does not have a direct role in promoting clotting or stopping bleeding.

<p>Erythropoietin injections can stimulate the production of red blood cells in the bone marrow.<br /> This therapy can increase the patient&#39;s hemoglobin levels and improve oxygen-carrying capacity, making it a suitable recommendation for a patient with hypoxia due to anemia.<br /> For , choic
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