Question 1

A 73-year-old client is about to receive a blood transfusion to treat severe anemia and asks the nurse how long the procedure will take. What is the most appropriate response?

Accepted Answer

Answer reason: Standard nursing practice is to complete each unit within 4 hours from the time it is started/removed from controlled storage. This timeframe also supports appropriate monitoring for transfusion reactions and maintaining product integrity. Longer durations (e.g., 8–24 hours) increase infection risk and are not considered safe transfusion practice for routine PRBC administration.

Question 2

The nurse is preparing to administer a transfusion of RBCs to the client with blood type AB negative. The blood bank does not have any units of AB negative PRBCs so provides a unit of O negative RBCs. What should the nurse do?

Accepted Answer

Answer reason: RBC compatibility is primarily determined by donor red-cell antigens and the recipient’s plasma antibodies; recipients must not have antibodies that will hemolyze donor RBCs. An AB-negative client has no anti-A or anti-B antibodies, and O-negative donor RBCs have neither A nor B antigens and are Rh-negative, making them compatible. Therefore, this unit is acceptable to administer as long as all standard transfusion checks and monitoring are performed. Returning the unit as incompatible reflects misunderstanding of RBC (not plasma) compatibility; obtaining consent is required for transfusion generally but is not the key compatibility decision point in this scenario.

Question 3

A 22-year-old female client receives Rho(D) immune globulin, human (Rhogam) after a sudden miscarriage. Which statement is true regarding this blood product?

Accepted Answer

Answer reason: Rh(D) immune globulin is a human plasma-derived immune globulin, so hypersensitivity reactions can occur, including rare anaphylaxis. Safe administration of blood products/immune globulins requires readiness to treat severe allergic reactions immediately, making emergency medications like epinephrine essential. It provides passive (not active) immunity and is given to Rh-negative clients to prevent maternal sensitization to fetal Rh-positive cells. Options describing use in Rh-positive clients or increasing antibody response are incorrect because the therapy works by preventing antibody formation.

Question 4

A client with type A positive blood receives type A negative blood. Which action should the nurse take when this discrepancy is noted?

Accepted Answer

Answer reason: The key principle is that ABO incompatibility is the major immediate transfusion risk, while Rh mismatch primarily matters when an Rh-negative recipient is exposed to Rh-positive blood. An A+ client receiving A− blood is receiving ABO-compatible red cells and lacks the D antigen that would trigger an anti-D response in an Rh-positive recipient. The appropriate nursing action is still to treat any identification discrepancy as a transfusion safety event by notifying the blood bank and provider to investigate and document. In contrast, drawing blood and sending the bag is typically indicated when a transfusion reaction is suspected and the transfusion is stopped, which is not specifically supported by this scenario alone.

Question 5

The nurse cares for a client receiving mechanical ventilation who is prescribed one unit of packed red blood cells to be transfused. Which finding would alert the nurse of a transfusion-related reaction?

Accepted Answer

Answer reason: Hemoglobin in the urine after starting a transfusion is a classic sign of acute hemolytic transfusion reaction due to ABO incompatibility, reflecting intravascular hemolysis. This reaction can rapidly progress to shock, DIC, and acute kidney injury, making it a high-priority “stop the transfusion” finding. In a mechanically ventilated client, respiratory changes can be subtle or attributed to ventilator issues, but hemoglobinuria is highly specific for hemolysis rather than equipment problems. A low-pressure alarm usually suggests a ventilator circuit disconnection or leak, and hyperglycemia is not a typical transfusion reaction indicator.

Question 6

A patient with type A negative blood requires a transfusion of packed red blood cells due to low hemoglobin values. Which blood type can be safely ordered and administered?

Accepted Answer

Answer reason: An A-negative patient has anti-B antibodies and must not receive any RBCs that carry B antigen, and they should receive Rh-negative blood to avoid anti-D sensitization. This choice matches both ABO (A antigen present, no B antigen) and Rh (D antigen absent), making it the safest and most appropriate selection. Options containing B antigen (B positive, AB negative) risk acute hemolysis, and Rh-positive blood (0 positive) risks Rh alloimmunization even though O is ABO-compatible.

Question 7

The nurse is caring for a client requiring an emergent transfusion of packed red blood cells. The nurse checks the blood bank, but the only available blood is O + (positive). The client's blood type is A+ (positive). What is the nurse's most appropriate action?

Accepted Answer

Answer reason: PRBC transfusion requires ABO/Rh verification and compatibility testing to prevent acute hemolytic transfusion reactions. An A+ client can typically receive A+ or O+ red cells, but the unit still must be cross-matched against the recipient’s serum unless it is a true life-threatening emergency where uncrossmatched blood is ordered per protocol. This action directly addresses immediate safety while allowing use of the only available compatible donor type for RBCs. Calling other banks or the family delays emergent therapy, and stating there is “no available blood” is inaccurate because a potentially suitable unit exists.

Question 8

A nurse is preparing to administer a unit of packed red blood cells to a patient who had a type & screen done three days ago. What should the nurse do before sending the request for the blood product?

Accepted Answer

Answer reason: Many facilities require a type & screen specimen to be collected within 72 hours of transfusion, because antibodies can develop after recent transfusion or pregnancy and may not have been detected previously. Since the sample is three days old, it is at/just beyond that typical validity window and the safest action is to obtain a fresh specimen before requesting blood. Simply proceeding or relying on prior verification does not address the time-sensitive validity of the compatibility sample.

Question 9

A nurse is monitoring a patient during a blood transfusion. The patient acutely develops flank and chest pain accompanied by hypotension, respiratory distress, and tachycardia. The nurse notes scant brownish discolored urine in the patient’s foley bag. Which of these answer choices correctly describes both the nurse’s first action as well as the name of this patient’s transfusion reaction?

Accepted Answer

Answer reason: Acute hemolytic transfusion reactions are life-threatening and present with fever/chills, flank or chest/back pain, hypotension, tachycardia, respiratory distress, and hemoglobinuria that can darken urine. The priority nursing principle is to remove the offending agent immediately to prevent further intravascular hemolysis and worsening shock/DIC/AKI. After stopping the blood, maintain IV access with normal saline using new tubing and notify the provider and blood bank for reaction workup. Epinephrine is reserved for anaphylaxis with urticaria/bronchospasm/angioedema rather than hemoglobinuria and flank pain.

Question 10

You are about to administer blood to a patient. You have verified that it is the correct blood for the patient with another nurse. What do you need to assess before you start the blood?

Accepted Answer

Answer reason: Baseline assessment before initiating a transfusion is essential to detect early signs of an acute transfusion reaction and to compare changes after the infusion starts. Temperature, blood pressure, pulse, respiratory rate, and oxygen saturation provide the most sensitive initial indicators of hemolytic, febrile, allergic, or circulatory overload reactions. These data guide immediate decisions such as slowing or stopping the transfusion and notifying the provider if abnormal changes occur. Laboratory values like hemoglobin and creatinine may influence the indication or monitoring plan, but they do not replace the immediate safety requirement of obtaining baseline vital signs right before starting.

Question 11

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

Accepted Answer

Answer reason: PRBCs directly replace lost red cell mass, improving tissue oxygen delivery and helping reverse tachycardia, hypotension, and weak pulses. Platelets are targeted for thrombocytopenia/platelet dysfunction with bleeding, and FFP is used mainly for coagulation factor replacement (e.g., warfarin reversal, DIC, massive transfusion coagulopathy), not as first-line for isolated acute blood loss. Granulocytes are reserved for severe neutropenia with refractory infection and do not treat hemorrhage.

Question 12

Following the initiation of blood products, how long must the nurse remain with the patient?

Accepted Answer

Answer reason: Remaining with the patient for the first 15 minutes allows the nurse to detect early signs such as fever/chills, flushing, dyspnea, back/chest pain, hypotension, or urticaria and stop the transfusion promptly. During this period the transfusion is typically started slowly to limit exposure if a reaction occurs. Shorter periods risk missing a rapidly evolving reaction, while longer times are not required as a constant bedside presence once the patient is stable and appropriate monitoring is established.

Question 13

Which of the following blood products should be infused rapidly?

Accepted Answer

Answer reason: Rapid infusion also helps ensure the intended hemostatic effect before ongoing consumption or bleeding worsens thrombocytopenia. In contrast, packed red blood cells are commonly infused more slowly (often over 1.5–4 hours per unit) to reduce risks such as circulatory overload, and FFP is infused at a rate appropriate to volume tolerance rather than as a general “rapid” standard. Dextran is a plasma volume expander, not a blood product, and its infusion rate depends on the clinical goal and patient status rather than standard blood component handling principles.

Question 14

This quiz will test your knowledge on the ABO blood types in preparation for the NCLEX exam. 1. What blood type is known as the "universal donor"?

Accepted Answer

Answer reason: Type O (specifically O negative in clinical practice) is considered the universal donor because its red blood cells lack A and B antigens, minimizing the risk of hemolytic transfusion reactions when given to recipients of any ABO type. This makes it the safest option in emergency transfusions when the recipient’s blood type is unknown.

Question 15

In emergency which blood group can be used?

Accepted Answer

Answer reason: In emergency situations when the patient’s blood type is unknown, type O blood (specifically O negative) is used because it lacks A and B antigens, minimizing the risk of acute hemolytic transfusion reactions. This makes it the safest universal donor option.

Question 16

The indication for exchange transfusion ?

Accepted Answer

Answer reason: Exchange transfusion is primarily indicated in severe hemolytic disease of the newborn (e.g., Rh incompatibility) to rapidly remove circulating bilirubin and maternal antibodies while replacing them with compatible donor blood. This helps prevent kernicterus and correct anemia. The other conditions (DIC, ITP, vitamin K deficiency) are managed with targeted therapies such as clotting factors, platelets, or vitamin K rather than exchange transfusion.

Question 17

The universal donor blood group is?

Accepted Answer

Answer reason: O negative blood lacks A, B, and Rh antigens, making it least likely to trigger an immune response in recipients. Therefore, it can be safely transfused in emergencies when the recipient’s blood type is unknown.

Question 18

Which blood type is considered the universal donor?

Accepted Answer

Answer reason: O negative blood does not contain A, B, or Rh antigens, minimizing the risk of hemolytic reactions. It is universally compatible for red blood cell transfusion.

Question 19

The nurse cares for a client receiving a transfusion of single-donor platelets collected via apheresis. What does the nurse teach the new graduate nurse about single-donor platelet transfusions?

Accepted Answer

Answer reason: Apheresis single-donor platelets decrease donor exposure compared with pooled/random-donor platelets, which lowers the risks of alloimmunization and transfusion-transmitted infections—important for patients who require repeated platelet support. Using fewer donors is a key strategy for clients with ongoing thrombocytopenia who may need many transfusions over time. In contrast, allergic reactions are more related to plasma proteins and can still occur with single-donor products, so this is not reliably reduced. While specific clinical populations (e.g., transplant) often receive specially selected platelets (e.g., leukoreduced/irradiated), the defining teaching point of single-donor platelets is reduced donor exposure for repeated transfusions.

Question 20

A nurse prepares to administer 2 units of packed red blood cells (PRBCs) to a client with type O negative blood. Which donor blood type is the safest to administer?

Accepted Answer

Answer reason: A client with type O negative has anti-A and anti-B antibodies and should not receive RBCs that carry A or B antigens, eliminating A negative and AB negative. Because the client is Rh-negative, administering Rh-positive blood (O positive) can trigger anti-D formation and cause reactions now or in future exposures (especially important for those with childbearing potential). Using O negative PRBCs provides RBCs without A, B, or D antigens, making it the safest match.

Question 21

A client is receiving a first-time blood transfusion of packed RBC. How long should the nurse stay and monitor the client to ensure a transfusion reaction will not happen?

Accepted Answer

Answer reason: g., acute hemolytic or severe allergic reactions) typically occur early, often within the first 10–15 minutes of starting the infusion. Nursing standards therefore require the nurse to remain with the client and closely assess vital signs and symptoms during this initial period when risk is highest. Starting the transfusion slowly and performing frequent reassessment allows rapid recognition of fever/chills, flank pain, dyspnea, urticaria, or hypotension and immediate stopping of the transfusion. Longer timeframes may still require ongoing periodic monitoring, but they are not the key “stay at bedside” window emphasized for early reaction detection.

Question 22

A nurse is caring for a patient who is receiving a blood transfusion. Which of the following is the most important to monitor for during the first 15 minutes after the transfusion begins?

Accepted Answer

Answer reason: An acute hemolytic reaction (often ABO incompatibility) can rapidly progress to fever/chills, back or flank pain, dyspnea, hypotension, hemoglobinuria, shock, and DIC, requiring immediate cessation of the transfusion and urgent intervention. Monitoring specifically for this syndrome is more clinically critical than isolated, nonspecific symptoms. Although hypotension can occur, it is a downstream manifestation shared by multiple reactions and is best captured within the broader need to detect hemolysis early. Focusing on early hemolytic signs supports prompt stop-the-transfusion action and prevents catastrophic complications.

Question 23

Redd is receiving a blood transfusion. When monitoring the patient, the nurse would analyze an elevated body temperature as indicating?

Accepted Answer

Answer reason: Fever during or shortly after a transfusion is a key early warning sign of an acute transfusion reaction and must be treated as potentially serious until proven otherwise. The nurse should suspect this because immune-mediated reactions (e.g., febrile nonhemolytic reaction, acute hemolytic reaction, bacterial contamination) commonly present with a temperature rise and can rapidly progress. Sepsis is possible in general, but in the immediate context of a transfusion, a new fever is most concerning for a transfusion-related complication and prompts stopping the transfusion and initiating the reaction protocol. Calling it “expected” or “normal” is unsafe because it can delay recognition of a life-threatening event.

Question 24

Nurse Jessica is monitoring a patient who is receiving a platelet transfusion. To evaluate the effectiveness of the therapy, what positive outcome should she look for?

Accepted Answer

Answer reason: Platelet transfusions are given to correct thrombocytopenia or platelet dysfunction and thereby improve primary hemostasis (platelet plug formation). The most direct clinical indicator of effectiveness is reduced mucocutaneous bleeding such as petechiae, epistaxis, gum bleeding, or oozing from IV/line sites. Hemoglobin and hematocrit primarily reflect red blood cell mass and are expected to change with packed RBC transfusion or ongoing blood loss, not from platelet administration. Febrile episodes are more consistent with infection or a transfusion reaction rather than a therapeutic goal of platelets.

Question 25

A 16-month-old toddler is admitted to the hospital for severe anemia secondary to insufficient iron intake. The child's hemoglobin is 8 grams/dL and hematocrit is 23%. A blood transfusion is ordered. During the transfusion, the nurse’s priority in assessment would be?

Accepted Answer

Answer reason: Acute transfusion reactions most often present early with fever and/or chills, so frequent monitoring is the most sensitive priority assessment during administration. A rising temperature may indicate a febrile nonhemolytic reaction or a potentially life-threatening hemolytic reaction, requiring the nurse to stop the transfusion and initiate the reaction protocol promptly. While pulse and respirations can change with reactions, they are less specific and may lag behind the earliest warning sign of fever. Rash suggests an allergic reaction, but fever surveillance provides the earliest broad safety screen for several serious transfusion complications.

Question 26

Packed red blood cells are stored at?

Accepted Answer

Answer reason: Standard blood bank storage for packed RBCs is at refrigerated temperatures (about 1–6°C, often taught as 2–6°C or 2–8°C in exam settings). Room temperature storage (22–24°C) is used for platelets, not RBCs, because platelet function requires warmer conditions with agitation. Freezing at -4 to -6°C is not an appropriate routine storage range for packed RBC units and risks hemolysis without proper cryopreservation. Temperatures near 30–36°C would accelerate degradation and markedly increase contamination risk.

Question 27

A client is brought to the emergency department having experienced blood loss related to an arterial laceration. Which blood component should the nurse expect the health care provider to prescribe?

Accepted Answer

Answer reason: This product increases hemoglobin/hematocrit with less volume than whole blood, making it appropriate for significant blood loss from an arterial laceration. Fresh-frozen plasma is used mainly to replace clotting factors (e.g., coagulopathy, warfarin reversal, massive transfusion protocols with documented factor depletion) rather than isolated blood loss. Platelets treat thrombocytopenia or platelet dysfunction, and granulocytes are rarely used and reserved for severe neutropenia with life-threatening infection.

Question 28

The nurse is caring for a patient receiving a blood transfusion. On assessment, the nurse notes that the patient's respirations are rapid, the face is flushed, and the patient is complaining of itching. The nurse suspects the patient is having a transfusion reaction. The nurse should accomplish the following actions: Take vital signs; Stop the transfusion; Administer oxygen; Obtain a urine specimen. The nurse should complete the tasks in the following order?

Accepted Answer

Answer reason: Rapid respirations, flushing, and pruritus are consistent with an acute allergic/transfusion reaction, making interruption of the transfusion the most time-critical action. After stopping, the nurse then assesses and supports oxygenation and hemodynamics (vital signs, oxygen) while maintaining IV access with appropriate fluids per protocol. Urine specimen collection is useful for evaluating hemolysis (e.g., hemoglobinuria) but is a later, non–life-saving step compared with stopping the infusion and stabilizing the patient.

Question 29

A client has elected to receive an autologous blood transfusion after surgery. The nurse should assess for which signs and symptoms indicating a transfusion reaction?

Accepted Answer

Answer reason: The most typical early findings are fever and chills, often accompanied by autonomic changes such as tachycardia. By contrast, hemoglobinuria with low back pain is more characteristic of an acute hemolytic reaction, which is far less likely with properly matched autologous units. Nonspecific GI symptoms alone are not a classic transfusion reaction pattern and should not be the primary expected assessment finding.

Question 30

Two days following a repair for an abdominal aortic aneurysm, a client requires 1 unit of packed red blood cells (PRBCs) for hemoglobin of 7.6 g/dL and hematocrit of 23.1%. After receiving the PRBCs from the blood bank, which action does the nurse perform first at the client's bedside?

Accepted Answer

Answer reason: Once blood has arrived to the bedside, the nurse’s first action there is to perform the required two-person verification against the client identifiers and blood product label before any connection to the IV tubing occurs. Baseline vital signs are important for later comparison if a reaction occurs, but they do not prevent the highest-risk error of wrong blood to the wrong patient. Consent and IV access should already be ensured before requesting/obtaining the unit, and they are not the first bedside step after the product is received.

Question 31

Your client has an order for one unit of packed red blood cells. One of the other nurses picked the blood up at the blood bank at 11 am and you began the infusion of the packed red blood cells at 12 noon after you have completed all of the safety, client identification and preparation procedures. At what time should this unit of packed red blood cells be completely infused?

Accepted Answer

Answer reason: Packed RBCs must be completed within 4 hours of starting the transfusion to reduce the risk of bacterial proliferation and hemolysis at room temperature. Since the infusion begins at 12 noon, the latest safe completion time is 4 hours later. The pickup time from the blood bank affects when the unit should be started (generally within ~30 minutes of receipt), but once started the governing limit is the 4-hour maximum infusion window. Finishing earlier may be clinically appropriate for some patients, but the question asks the required completion deadline based on transfusion standards.

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