The Nurse Is Administering the Second Units of Whole Blood to an Older Adult Client Who Was Admitted Yesterday with Gastrointestinal (Gl) Feeding Which Paramet

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Sample questions from The Nurse Is Administering the Second Units of Whole Blood to an Older Adult Client Who Was Admitted Yesterday with Gastrointestinal (Gl) Feeding Which Paramet

This material has 90 questions with answers and rationales. Here are the first 5.

1. 1.In a medical-surgical unit, a 76-year-old admitted with a gastrointestinal bleed is receiving the second ordered unit of whole blood. Fifteen minutes after the transfusion begins, the client reports chills and back pain; temperature rises from 37.0 C to 38.2 C. Which action should the nurse take first?

   • A.Administer the prescribed antipyretic and continue the transfusion
   • B.Slow the transfusion and reassess the temperature in 15 minutes
   • C.Stop the transfusion and maintain IV access with normal saline using new tubing
   • D.Send a blood sample to the laboratory before changing the infusion

   Rationale: Chills, back pain, and an acute temperature rise suggest a potentially serious transfusion reaction, so the blood must be stopped immediately. Maintain access with normal saline through new tubing and then notify the provider and blood bank and follow the reaction protocol. Slowing or continuing the blood risks further harm, and collecting specimens does not take priority over stopping the exposure.

2. 2.At change of shift on a medical unit, a 68-year-old with a gastrointestinal bleed has an order for whole blood. Which action is appropriate for the registered nurse to delegate to experienced unlicensed assistive personnel (UAP)?

   • A.Determine whether the client understands transfusion risks
   • B.Verify the client's identity against the blood product label
   • C.Assess the client for new dyspnea during the transfusion
   • D.Obtain and report the client's routine pretransfusion vital signs

   Rationale: A UAP may obtain routine vital signs on a stable client and promptly report the results. Two qualified clinicians must perform the required blood product and identity verification according to policy. Assessment for complications and evaluation of understanding require nursing judgment and cannot be delegated to UAP.

3. 3.On a medical unit, a 79-year-old with a bleeding gastric ulcer is about to receive the second unit of whole blood. The client is stable and asks what will happen before the unit starts. Which actions should the nurse take before initiating it? Select all that apply.

   • A.Warm the blood in a microwave if the client reports feeling cold
   • B.Verify the prescription and consent status
   • C.Confirm that patent IV access and normal saline are available
   • D.Inspect the unit for leaks, clots, or unusual discoloration
   • E.Prime the blood administration set with dextrose solution
   • F.Use two qualified staff members to verify client identity and product details per policy

   Rationale: The nurse confirms the order and consent, completes the required independent product and identity checks, inspects the unit, and ensures appropriate IV access and normal saline are ready. Dextrose is not used to prime blood tubing because it can damage red blood cells; normal saline is compatible. Blood must never be warmed in a microwave; only an approved blood warmer is used when indicated.

4. 4.In a telemetry unit, a 72-year-old with a gastrointestinal hemorrhage has a hemoglobin of 6.8 g/dL and an order for whole blood. Which task is appropriate for the nurse to assign to an experienced LPN/LVN?

   • A.Reinforce teaching about reporting itching, chills, or shortness of breath
   • B.Administer the blood and independently manage any transfusion reaction
   • C.Make the initial assessment of the client's readiness for transfusion
   • D.Obtain informed consent from the client

   Answer and rationale are in the full material.

5. 5.A provider prescribes the second unit of whole blood for a 70-year-old in the emergency department with ongoing melena. The first unit finished 3 hours ago, and the client is now pale with HR 118/min and BP 88/54 mm Hg. What should the nurse do first?

   • A.Ask the UAP to start the blood while the nurse calls the provider
   • B.Begin the prescribed blood promptly after required verification and assessment
   • C.Give oral fluids and reassess blood pressure in 30 minutes
   • D.Wait for a repeat hemoglobin result before acting

   Answer and rationale are in the full material.