Blood Administration Posttest

Skills Module 3.0: Blood Administration Posttest 3 CLOSE Question: 1 of 10 CORRECT Time Remaining: 08:19:39 Pause Remaining: 08:20:00 PAUSE FLAG A nurse is caring for a client who is about to receive a unit of packed RBCs and states, "This is my third unit of blood today. I don't want to get some disease from all this blood." Which of the following responses should the nurse make? ☐ 'It is impossible for you to get an infection from donor blood." INCORRECT This statement is not entirely true. Although the risk is low, disease transmission through blood transmission is possible. Improvements in blood-processing methods have reduced the number of infections resulting from the use of these blood products, but they have not eliminated them. Currently, the risk of blood-borne infection through receiving a blood transfusion or blood products in the U.S. is extremely low and has become progressively lower, but there is no absolute guarantee of safety. "Donated blood is carefully screened for infectious diseases" CORRECT This statement is accurate. The nurse might continue to explain that the approach to blood safety in the U.S. includes stringent donor selection practices and the use of screening tests for HIV, AIDS, hepatitis B and C, syphilis, and other infectious diseases. Infected blood and blood products are safely discarded and are not used for transfusions. "The U.S. blood supply is among the safest in the world." INCORRECT Although this statement is true, it offers an empty type of reassurance without any solid information to address the client's fears, in fact, giving reassurance is a nontherapeutic communication technique. It implies that there is no need for concern and devalues the client's feelings, which might discourage them from further expression of their concerns. Blood administration Posttest Study Materials INCORRECT This is response is inappropriate not only because there might not be any other treatment options that offer comparable or better therapeutic benefits for this client, but by suggesting other options, the nurse is risking increasing the client's fears about transfusion. This response can sound as though the nurse is confirming that the dient's concerns about infectious disease are entirely realistic. Assessments This is standard procedure, because most transfusion reactions, including those related to bicod-type incompatibilities, manifest during the infusion of the first 50 to 100 mL of the blood product and possibly sooner. This procedure helps detect, not prevent, the possibility of a blood-group incompatibility. Which of the following actions should a nurse take prior to starting a blood transfusion? Establish intravenous access with a 22-gauge needle. INCORRECT Blood is too viscous to infuse properly through a needle with a lumen this narrow. It is best to use an 18-or 19-gauge needle. Prime an infusion set with lactated Ringer's solution. INCORRECT Blood is always administered with 0.9% sodium chloride solution, and never with a solution that contains dextrose, because it causes lysis of red blood cells, or with lactated Ringer's. Ensure that informed consent has been obtained from the client. CORRECT It is the responsibility of the prescribing health care provider to answer the client's questions about the need, risks, and benefits of a procedure. A nurse can witness the client's signature indicating informed consent. This must be done prior to obtaining or administering the blood. Suggest that the client consider autologous transfusion. INCORRECT Autologous transfusion is the process of collecting, storing, and reinfusing the client's own blood. It is an alternative for dients who choose not to receive blood components from recruited blood donors, but it is not possible in all situations. Typically it must be planned in advance and some clients are not eligible for it. There would be no need to suggest an autologous transfusion to a client who has no objection to a standard blood transfusion. 1/2 A nurse is caring for a client who is receiving a blood transfusion and reports itching. The nurse observes areas of urticaria on the client's skin. Which of the following actions should the nurse take? ... Administer prescribed antipyretic INCORRECT The nurse would administer a prescribed antihistamine for this client, not an antipyretic. Stop the blood transfusion. CORRECT This client is exhibiting manifestations of a mild allergic reaction to the blood transfusion. The nurse should stop the transfusion and follow facility protocol regarding transfusion reactions. Reevaluate the client in 15 min. INCORRECT Delaying intervention could potentially lead to poor outcomes for the client. While itching and urticaria are signs of a mild allergic reaction, they might also be signs of more serious transfusion reactions such as anaphylaxis. Apply a warm compress to the affected areas. INCORRECT To relieve the itching associated with urticaria, the nurse should apply a cool compress to the area.