Question 1

A client who is receiving a blood transfusion experiences a hemolytic reaction. The nurse would anticipate which of the following assessment findings?

Accepted Answer

Answer reason: Acute hemolytic transfusion reactions (often due to ABO incompatibility) present with fever, hypotension, chills, tachycardia, and characteristic flank/low back pain from hemoglobinuria—findings listed in option 1. Other options describe circulatory overload, febrile nonhemolytic, and allergic reactions.

Question 2

Before you Blood donate, you will be...?

Accepted Answer

Answer reason: Pre-donation screening includes verifying that the donor meets minimum weight criteria, measuring blood pressure to ensure it is within an acceptable range, and confirming the date of the last donation to observe the required interval (e.g., about 8 weeks for whole blood). These checks protect donor safety and help ensure a safe, usable blood product. Therefore, all listed actions are performed before blood donation.

Question 3

What is 1 unit of blood millilitres?

Accepted Answer

Answer reason: A standard unit of whole blood collected for transfusion is 450 mL (±10%), not including the anticoagulant solution. Collection bags often contain about 63 mL of additive, bringing the total bag volume to roughly 500 mL, but the unit itself is defined as 450 mL of blood. Therefore, 450 mL is the best answer.

Question 4

Donated blood is usually taken from?

Accepted Answer

Answer reason: Whole blood donation is obtained by venipuncture from a large peripheral vein, typically in the antecubital fossa (e.g., median cubital vein). Veins are low-pressure and have thinner walls, making access safer and minimizing bleeding and complications. Arteries are high-pressure and not used for routine blood collection, capillaries are for small-volume sampling, and nerves are not blood vessels.

Question 5

What's the common side effect of massive blood transfusion?

Accepted Answer

Answer reason: During massive transfusion, citrate in stored blood binds ionized calcium, leading to hypocalcemia. This can cause paresthesias, tetany, hypotension, and arrhythmias, so calcium levels must be monitored and replaced as needed. Fever and allergic reactions are general transfusion reactions but are not characteristic of massive transfusion physiology. Hypokalemia is unlikely; stored blood more commonly causes hyperkalemia.

Question 6

What is the first nursing intervention if a patient develops a fever during a transfusion?

Accepted Answer

Answer reason: A fever during a blood transfusion may indicate a transfusion reaction (e.g., febrile non-hemolytic reaction, acute hemolytic reaction, or bacterial contamination), which can rapidly become life-threatening. The priority first action is to stop the transfusion to prevent further exposure to the suspected causative blood product. After stopping, the nurse would typically maintain IV access with normal saline using new tubing, assess vital signs, and notify the provider/blood bank per protocol. Giving antipyretics or slowing the rate can delay recognition and worsen outcomes if the reaction is more severe.

Question 7

Which blood group is Universal Donor?

Accepted Answer

Answer reason: O-negative blood lacks A, B, and Rh (D) antigens on red blood cells, which minimizes the risk of acute hemolytic transfusion reactions. Because it does not carry these major antigens, O-negative blood can be safely transfused to patients of any ABO or Rh blood type in emergency situations when crossmatching is not immediately available.

Question 8

Which blood group is called “Universal Donor”?

Accepted Answer

Answer reason: O-negative blood lacks A, B, and Rh antigens, making it least likely to cause an immune reaction when transfused to recipients of any blood type. For this reason, O-negative is considered the universal donor, especially in emergency situations when blood type is unknown.

Question 9

Midway through a blood transfusion, a patient complaints of severe back pain. What should the nurse do?

Accepted Answer

Answer reason: Severe back/flank pain during a transfusion is a red-flag sign of an acute hemolytic transfusion reaction, which can rapidly progress to shock, hemoglobinuria, and renal failure. The priority nursing action is to stop the transfusion immediately and assess the patient (including vital signs) while escalating to the nurse in charge/provider and following transfusion-reaction protocol. Reassurance, speeding up the transfusion, or masking symptoms with analgesia can delay recognition and worsen harm. Stopping the transfusion is the key first step to prevent further antigen exposure.

Question 10

Which blood product is given in massive hemorrhage?

Accepted Answer

Answer reason: In massive hemorrhage, the immediate priority is restoring oxygen-carrying capacity and circulating volume, which is achieved with packed red blood cells (PRBCs). PRBCs directly replace lost red cells and improve tissue oxygen delivery, helping reverse shock. Fresh frozen plasma and platelets are important to correct dilutional/consumptive coagulopathy in massive transfusion protocols, but they do not replace oxygen-carrying capacity. Albumin is a volume expander and is not the primary blood product for acute massive blood loss.

Question 11

What is the longest duration allowed for blood product infusion after removal from refrigeration?

Accepted Answer

Answer reason: Blood components (especially packed RBCs) must be completed within 4 hours of being removed from controlled refrigeration to reduce the risk of bacterial proliferation and hemolysis at room temperature. This “4-hour rule” is a core transfusion-safety standard and applies to the total time from issuance/room temperature exposure to completion of infusion. Shorter options (e.g., 30 minutes) relate to how quickly to start/return unused blood to the blood bank, not the maximum infusion duration. Longer durations (6 hours) exceed standard safe transfusion time limits.

Question 12

Which gauge use for blood transfusion?

Accepted Answer

Answer reason: Blood transfusion requires an IV catheter large enough to allow adequate flow while minimizing hemolysis and avoiding damage/clotting of blood components in the tubing. A larger-bore peripheral IV (commonly 18G; 16G for rapid/massive transfusion) is standard for routine adult blood administration. Smaller gauges (20–26G) can restrict flow, prolong transfusion time, and may be inadequate when faster administration is needed. Therefore, 16–18G is the best choice among the options.

Question 13

The universal donor blood group is?

Accepted Answer

Answer reason: Blood group O negative lacks A, B, and Rh (D) antigens, making it the safest option for emergency transfusions when the recipient’s blood type is unknown. Because it minimizes the risk of hemolytic transfusion reactions, O-negative blood is universally accepted as the universal donor type.

Question 14

The nurse prepares for blood transfusion in a woman with APH. Which step should be done first?

Accepted Answer

Answer reason: The first priority in preparing for a blood transfusion is to prevent a catastrophic mismatch reaction by verifying the correct patient and the correct blood product, which requires an independent double-check with another nurse per transfusion safety standards. Checking the bag for clots/leaks and priming the tubing with normal saline are important but occur after correct patient-product verification is ensured. Documentation of consent is required, but the critical first safety step at the bedside before initiating transfusion processes is identity verification.

Question 15

A patient receiving a blood transfusion suddenly develops chills, back pain, and shortness of breath. What is the first action the nurse should take?

Accepted Answer

Answer reason: Chills, back pain, and shortness of breath during a transfusion are concerning for an acute transfusion reaction (including hemolytic reaction), which is a medical emergency. The priority nursing action is to stop the transfusion immediately to prevent further infusion of the offending blood product, while maintaining IV access with normal saline using new tubing. After stopping the transfusion, the nurse then assesses the patient, notifies the provider and blood bank, and follows transfusion reaction protocol (including verification and sending blood/tubing as required).

Question 16

A client is going to be transfused with a unit of packed red blood cells (PRBCs). The nurse understands that it is necessary to remain with the client for what time period after the transfusion is started?

Accepted Answer

Answer reason: 15 minutes. Most acute transfusion reactions (e.g., hemolytic reaction, anaphylaxis, TRALI) occur early, often within the first 10–15 minutes of starting PRBCs. The nurse must stay with the client during this initial period to directly observe for fever/chills, dyspnea, hypotension, back/chest pain, or hives and stop the transfusion immediately if they occur. After this period, ongoing monitoring continues at prescribed intervals, but continuous bedside presence is most critical during the first 15 minutes.

Question 17

A client who was receiving a blood transfusion has experienced a transfusion reaction. The nurse sends the blood bag that was used for the client to which area?

Accepted Answer

Answer reason: The blood bank. After a suspected transfusion reaction, the blood product and tubing are typically returned to the blood bank for repeat compatibility testing, inspection for hemolysis, and investigation of any clerical or product issues. This supports rapid identification of the reaction type and helps prevent harm to other patients from implicated units. Sending it to the pharmacy, general laboratory, or risk management does not meet the immediate clinical requirement for transfusion reaction workup and product traceability.

Question 18

Which blood group is a universal donor?

Accepted Answer

Answer reason: O-negative blood lacks A, B, and Rh antigens, making it safe for transfusion to patients of any blood type in emergencies.

Question 19

The nurse reviews a patient's complete blood count and notes a hemoglobin level of 7.5 g/dL. What is the priority action?

Accepted Answer

Answer reason: Prepare for blood transfusion A hemoglobin of 7.5 g/dL indicates significant anemia with reduced oxygen-carrying capacity; transfusion is commonly indicated around

Question 20

The nurse is assisting with caring for a client who has received a transfusion of platelets. The nurse determines that the client is benefiting most from this therapy if the client exhibits which finding?

Accepted Answer

Answer reason: A decrease in oozing from puncture sites and gums. Platelet transfusions are given to treat thrombocytopenia or platelet dysfunction and are expected to improve primary hemostasis. Clinical improvement is demonstrated by reduced bleeding manifestations such as oozing from IV/puncture sites, gums, petechiae, or epistaxis. Hemoglobin/hematocrit reflect red blood cell mass and would respond to RBC transfusion, not platelets. Temperature normalization is not a direct indicator of platelet effectiveness and could relate to infection or transfusion reaction resolution instead.

Question 21

A patient is receiving a blood transfusion. After 15 minutes, the patient reports chills, itching, and back pain. What is the priority nursing action?

Accepted Answer

Answer reason: Stop the transfusion and notify the provider Chills, pruritus (itching), and especially back pain shortly after starting a transfusion are concerning for an acute transfusion reaction (e.g., hemolytic or other serious reaction). The priority nursing action is to stop the transfusion immediately to prevent further exposure to the offending blood product and then notify the provider/blood bank per protocol. Slowing the rate, giving antihistamines while continuing, or simply flushing and monitoring can delay definitive management and worsen outcomes if this is a severe reaction.

Question 22

The nurse is assisting with caring for a client who is receiving a unit of packed red blood cells (PRBCs). The nurse should tell the client that it is most important to report which sign(s) immediately?

Accepted Answer

Answer reason: Chills, itching, or rash. These are classic early manifestations of an acute transfusion reaction (often allergic or febrile) and require immediate reporting so the transfusion can be stopped and the client assessed. Early recognition prevents progression to more severe reactions such as hemolysis, anaphylaxis, or shock. The other options are less specific for an acute transfusion reaction and are not typically immediate stop-the-transfusion symptoms.

Question 23

The nurse takes a client's temperature before giving a blood transfusion. The temperature is 100° F orally. What should the nurse do next?

Accepted Answer

Answer reason:  A pre-transfusion baseline temperature is needed because fever can indicate an underlying infection or a potential transfusion reaction if the temperature rises after starting blood. With an oral temperature of 100°F, the safest action is to hold the transfusion and notify the provider for further orders rather than masking the fever with acetaminophen or antihistamines. Starting the transfusion as prescribed could make it difficult to distinguish a new transfusion reaction from a pre-existing fever and may increase risk to the client.

Question 24

What is the appropriate nursing action during a blood transfusion reaction?

Accepted Answer

Answer reason: Immediate cessation of the blood product is the priority to prevent further antigen exposure and progression to severe hemolytic reaction or anaphylaxis. After stopping, the nurse maintains IV access with normal saline using new tubing and performs focused assessment/vital signs while initiating facility transfusion-reaction protocol. The provider and blood bank are notified promptly so the unit and tubing can be returned for investigation and additional orders (e.g., labs, supportive therapies) obtained.

Question 25

Universal Blood donor is……?

Accepted Answer

Answer reason: The universal blood donor is O Negative (O−). This blood type has no A antigen, no B antigen, and no Rh antigen, making it compatible with all other blood types in emergency transfusions. O Positive cannot be universal because Rh-negative recipients could react to the Rh antigen. AB Positive is considered the universal recipient, not the universal donor.

Question 26

Scenario: A patient reports chills and back pain 10 minutes after transfusion begins. What is the nurse's priority action?

Accepted Answer

Answer reason: Chills and back pain shortly after initiating a transfusion are red flags for an acute transfusion reaction (including hemolytic reaction), which can rapidly progress to shock, renal failure, and DIC. The immediate safety action is to stop the blood product to prevent further exposure and then promptly notify the provider to initiate emergency management. After stopping, nursing actions typically include maintaining IV access with normal saline using new tubing and preparing to follow institutional protocol (e.g., vitals, labs, and blood bank notification). Slowing the infusion or documenting alone delays definitive response and increases risk of severe complications.

Question 27

A client with anemia in pregnancy has hemoglobin 7.2 g/dL. What is the most appropriate action?

Accepted Answer

Answer reason: A hemoglobin of 7.2 g/dL in pregnancy indicates severe anemia with reduced oxygen-carrying capacity and increased risk of maternal decompensation and fetal hypoxia, especially if symptomatic or near delivery. Transfusion is the most rapid method to restore circulating red cell mass when hemoglobin is this low or when there are signs of hemodynamic compromise. Dietary changes and routine prenatal vitamins act too slowly and are insufficient for severe anemia, and expecting spontaneous improvement is unsafe. Ongoing evaluation for cause (e.g., iron deficiency, hemoglobinopathy) and iron replacement should follow stabilization.

Question 28

A nurse is preparing to administer a dose of platelets to a client. Which of the following actions must the nurse perform before giving the platelets?

Accepted Answer

Answer reason: An intact, undamaged container helps ensure sterility and that the product has not leaked, clotted abnormally, or been compromised during storage/transport. Starting an IV with 0.45% saline is unsafe because hypotonic solutions can cause hemolysis; compatible fluid for blood products is 0.9% normal saline when needed. Verifying identity is essential, but “name and address” is not the standard two-identifier transfusion check (typically name and DOB/medical record number with product verification), making it less precise than the required product integrity check in this item.

Question 29

A client has received 2 units of whole blood today following an episode of GI bleeding. Which of the following laboratory reports would the nurse monitor most closely?

Accepted Answer

Answer reason: Monitoring these values helps confirm that the transfused blood has improved circulating red cell mass and alerts the nurse to ongoing or recurrent bleeding when levels fail to rise or begin to fall again. Bleeding time is an outdated/limited assessment of platelet function and does not directly reflect restoration of oxygen delivery after transfusion. Platelets and WBCs may be followed for other reasons, but they are not the most direct indicators of response to whole-blood transfusion for hemorrhage.

Question 30

The nurse is caring for a client with sickle cell disease who is scheduled to receive a unit of packed red blood cells. Which of the following is an appropriate action for the nurse when administering the infusion?

Accepted Answer

Answer reason: Packed red blood cells should be infused so the entire unit is finished within 4 hours from removal from controlled storage. If fever or chills occur, the safe response is to stop the transfusion and evaluate for a transfusion reaction rather than merely slowing the rate. Routine vital-sign frequency is highest at baseline and early in the transfusion, but not every 15 minutes for the entire duration unless agency policy or patient condition warrants it.

Question 31

Red Blood Cells The maximum transfusion time for a unit of packed red blood cells (RBCs) is?

Accepted Answer

Answer reason: The widely tested nursing standard is to finish a unit within 4 hours of starting the transfusion (and typically within 4 hours of removal from the blood bank, depending on policy). Longer times increase infection risk and can compromise red cell viability, so 6 hours is unsafe. Shorter limits like 2–3 hours may be used in specific clinical situations or rapid transfusion protocols, but they are not the maximum allowed duration.

Question 32

The nurse is preparing to administer blood to a client who requires postoperative blood replacement. The nurse should use a blood administration set that has a?

Accepted Answer

Answer reason: Blood transfusions require an in-line filter to trap clots, fibrin strands, and cellular aggregates to reduce the risk of embolic/infusion complications. Standard blood administration tubing includes a mesh filter (commonly around 170–260 microns) specifically designed for routine packed RBC administration. A nonfiltered set is unsafe because it allows microaggregates and clots to infuse. Leukocyte-reduction filters are used only when specifically indicated (e.g., to reduce febrile nonhemolytic reactions/CMV transmission risk), not as the routine required feature for postoperative replacement.

Question 33

A nurse is preparing to administer a unit of packed red blood cells (PRBC) to an adult client. Which of the following actions should the nurse take?

Accepted Answer

Answer reason: An 18-gauge (or larger) peripheral catheter is a standard choice for most adults, supporting safer administration and faster rates if clinically needed. Lactated Ringer’s is not compatible for priming blood tubing because calcium can promote clotting in citrated blood; only 0.9% normal saline should be used. Blood should not hang at room temperature for an hour before starting because it increases risk for bacterial growth and product degradation; initiate promptly and complete within the facility’s time limits (commonly within 4 hours of release).

Question 34

Which of the following is a sign or symptom of a hemolytic reaction to blood transfusion?

Accepted Answer

Answer reason: This classically produces dark/red urine due to hemoglobin in the urine and may be accompanied by fever, chills, flank/back pain, and hypotension. Urticaria is more characteristic of a mild allergic transfusion reaction, while distended neck veins suggests circulatory overload (TACO). Recognizing hemoglobinuria is critical because hemolysis can precipitate acute kidney injury and DIC, requiring immediate cessation of the transfusion and supportive management.

Question 35

The emergency department (ED) nurse cares for a client with severe intrabdominal bleeding. The client has tachycardia, hypotension, and a thready pulse. The nurse anticipates the PHCP will prescribe which blood product?

Accepted Answer

Answer reason: This presentation (tachycardia, hypotension, thready pulse) indicates significant acute blood loss requiring rapid replacement of red cell mass to improve tissue oxygen delivery. PRBCs are the standard product for acute hemorrhage because they increase hemoglobin/hematocrit without the extra volume of whole blood. FFP is used mainly to replace clotting factors in coagulopathy/massive transfusion, and platelets are indicated for thrombocytopenia or platelet dysfunction rather than isolated blood loss.

Question 36

A client involved in a major vehicle accident has type O blood. Which blood types can this client receive?

Accepted Answer

Answer reason: ABO compatibility is based on avoiding donor red blood cell antigens that the recipient has antibodies against. A person with type O blood has anti-A and anti-B antibodies, so receiving type A, B, or AB red cells would risk an acute hemolytic transfusion reaction. Type O red cells lack A and B antigens, making them the only safe ABO choice for a type O recipient. In urgent trauma care, O-negative is often used empirically until type-specific crossmatched blood is available, but within ABO types the recipient should still receive type O.

Question 37

The nurse receives a unit of blood at 0800 for transfusion. This unit of blood must be infused by what time?

Accepted Answer

Answer reason: Packed red blood cells must be completed within 4 hours of removal from controlled storage to limit bacterial proliferation and hemolysis risk. Starting from 0800, the latest safe completion time is 1200, but the question asks by what time the unit must be infused, which in many nursing test items is interpreted as the maximum allowable window from receiving/issuing until completion being 4 hours after starting; however, when anchored to 0800 receipt and assuming immediate initiation is delayed, the conservative and standard teaching is completion within 4 hours of starting once spiked, and many exam keys treat “received at 0800” as “start at 0800,” yielding 1200. Given the provided choices include 1600 as 8 hours after receipt, this aligns with the older/incorrect 8-hour rule; nevertheless, current NCLEX-aligned practice is 4 hours. Because the option set suggests a single expected maximum that matches common test-bank convention of 4 hours after initiation, the best supported answer is 1200; selecting otherwise would increase infection risk.

Question 38

A neonate requires blood transfusions after birth. Which cannulation site is most appropriate for the nurse to select?

Accepted Answer

Answer reason: Umbilical venous catheterization provides immediate central access in the newborn period and is commonly used for blood products and other emergent infusions. Scalp veins are peripheral, smaller, and more prone to infiltration/extravasation and are less suitable for transfusing larger volumes. Intraosseous access is generally a rescue route for emergencies when IV/central access cannot be obtained, and a subclavian cutdown is invasive and higher risk in a neonate.

Question 39

A client with a diagnosis of neutropenia would most likely be transfused with which substance?

Accepted Answer

Answer reason: Neutropenia is a critically low neutrophil count, creating high risk for severe infection, so replacement of functional white blood cells is the targeted transfusion strategy in select high-risk cases. Granulocyte transfusions provide donor neutrophils to temporarily augment host defenses when profound neutropenia is accompanied by serious infection or expected prolonged marrow suppression. Platelets are used for thrombocytopenia/bleeding risk, not low neutrophils. Fresh frozen plasma and cryoprecipitate primarily correct coagulation factor deficiencies rather than leukocyte deficits.

Question 40

A nurse is caring for a child with sickle cell anemia. The nurse anticipates that which type of transfusion is most likely to be given to the child?

Accepted Answer

Answer reason: This product provides concentrated red cells with less volume than whole blood, lowering the risk of fluid overload while effectively treating symptomatic anemia or preventing/treating complications (e.g., acute chest syndrome, perioperative needs, stroke risk protocols). Plasma is used primarily for coagulation factor replacement and would not correct the underlying anemia. Platelets are indicated for thrombocytopenia/platelet dysfunction and are not the routine transfusion need in uncomplicated sickle cell anemia.

Question 41

The nurse teaches a coworker about the treatment for hemophilia. The nurse instructs that the treatment will likely include periodic self-administration of which component?

Accepted Answer

Answer reason: Concentrated factor products are designed for home prophylaxis and on-demand therapy and can be taught for periodic self-infusion. Platelets and whole blood do not correct the specific factor deficiency and add unnecessary volume and transfusion risks. Fresh frozen plasma contains factors but is not preferred for routine self-administration because it requires larger volumes, has more transfusion-related risks, and factor concentrates provide more targeted, standardized dosing.

Question 42

Which is an advantage of using packed red cells for a client in need of a blood transfusion?

Accepted Answer

Answer reason: Packed red blood cells are concentrated erythrocytes with much of the plasma removed, so they deliver oxygen-carrying capacity with a smaller volume than whole blood. This lower transfused volume helps reduce the risk of transfusion-associated circulatory overload, especially in clients with heart failure, renal impairment, or the elderly. Clotting factors are primarily supplied by plasma products (e.g., FFP), not packed cells, making that distractor incorrect. Allergic reactions are more associated with donor plasma proteins; while washed products can reduce reactions, that is not the general advantage of standard packed cells compared with whole blood.

Question 43

The client who received 50 mL from a unit of whole blood has low back pain. In response to this client’s symptom, which action should be taken by the nurse first?

Accepted Answer

Answer reason: Low back/flank pain shortly after starting a transfusion is a classic warning sign of an acute hemolytic transfusion reaction, which can rapidly progress to shock, DIC, and acute kidney injury. The nurse’s priority is to immediately halt exposure to the offending blood product to prevent further hemolysis and deterioration. After stopping the transfusion, the nurse would maintain IV access with normal saline using new tubing and notify the provider and blood bank per protocol. Repositioning, further pain assessment, or giving an analgesic would delay the critical safety intervention and could mask worsening systemic reaction signs.

Question 44

Which nursing measure is an important aid in prevention of the crippling effects of joint degeneration caused by hemophilia?

Accepted Answer

Answer reason: Prompt and adequate clotting factor replacement (e.g., factor VIII or IX) stops joint bleeding early, reducing inflammation and subsequent cartilage destruction. By minimizing frequency and severity of joint bleeds, it directly prevents long-term joint degeneration and disability. In contrast, aspirin is contraindicated because it impairs platelet function and increases bleeding risk, and active ROM can worsen an acutely bleeding joint if started before hemostasis is achieved.

Question 45

A 17-year-old boy with classic hemophilia (hemophilia A) is admitted to the hospital for surgery. His preoperative preparation should include which treatment?

Accepted Answer

Answer reason: Replacing factor VIII before incision and maintaining therapeutic levels through and after the procedure is the key evidence-based intervention. Bed rest does not address the coagulation defect, and routine IV analgesics are not the primary pre-op requirement and may mask bleeding complications. Extra hydration is not a standard hemostatic strategy and does not reduce bleeding risk in factor deficiency disorders.

Question 46

A client has a history of positive HIV with onset of acquired immunodeficiency syndrome (AIDS). The client receives 2 units of whole blood. Which transfusion reaction is this client most likely to have?

Accepted Answer

Answer reason: Immunocompromised clients are at higher risk for transfusion-associated graft-versus-host disease because donor T lymphocytes can engraft and mount an immune attack against the recipient. Whole blood and non–leukoreduced cellular products contain viable lymphocytes, making this complication more likely in severe T-cell dysfunction such as AIDS. This reaction is classically prevented by irradiating cellular blood components for at-risk patients. In contrast, acute hemolytic reactions are primarily due to ABO incompatibility errors and are not specifically associated with HIV/AIDS status.

Question 47

A client receives a unit of packed red blood cells. Which is appropriate nursing care for this client?

Accepted Answer

Answer reason: Transfusion reactions most commonly occur early in the infusion, so establishing baseline vital signs and reassessing at 15 minutes is a core safety step for early detection of fever, hypotension, tachycardia, or respiratory compromise. The first minutes require close monitoring because even a small amount of incompatible blood can trigger an acute hemolytic or anaphylactic response. Limiting assessment to only BP/pulse/SpO2 is incomplete because temperature and respirations are essential to detect febrile and pulmonary reactions. Blood product verification must be performed by appropriately qualified licensed staff; a nurse’s aide is not permitted to complete the required identification checks.

Question 48

The HCP prescribes 5% albumin for four clients. The nurse should consult with the HCP if 5% albumin is prescribed for which client?

Accepted Answer

Answer reason: When a prescribed therapy may conflict with a client’s stated religious restrictions, the nurse must clarify acceptability and obtain informed consent before administration. Cerebral edema also requires careful selection of osmotic/oncotic therapies and close monitoring, so giving a potentially refused blood product without confirmation creates ethical and safety risk. In contrast, using albumin for hypovolemic shock or ARDS-related hypo-oncotic states can be clinically appropriate when indicated, but religious refusal is the clear reason to consult first.

Question 49

The African American child with thalassemia major has iron overload after receiving multiple blood transfusions. Which intervention should the nurse anticipate?

Accepted Answer

Answer reason: The appropriate intervention is to use an iron-chelating agent (e.g., deferoxamine, deferasirox, deferiprone) to bind iron and promote elimination to prevent organ damage. Reducing transfusion frequency is unsafe because transfusions are required to maintain adequate hemoglobin and suppress ineffective erythropoiesis in thalassemia major. Iron overload in this context is transfusion-related rather than something clarified by family history, so management targets removing accumulated iron rather than investigating heredity.

Question 50

A client who receives a blood transfusion complains of chest and low back pain. Vital signs are blood pressure 94/62 mm Hg, pulse 140 beats/minute, respiratory rate 32 breaths/minute. Which nursing action takes priority?

Accepted Answer

Answer reason: These findings during a transfusion (chest/low back pain with hypotension, tachycardia, and tachypnea) are most concerning for an acute hemolytic transfusion reaction, which can rapidly progress to shock, DIC, and renal failure. The first priority is to stop the transfusion to prevent further exposure to the incompatible blood product. After stopping, the nurse should keep IV access with normal saline using new tubing and then notify the provider and blood bank per protocol. Calling the provider first delays the immediate life-saving step, and Trendelenburg is not a primary intervention for a suspected transfusion reaction.

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