NCLEX blood transfusion reactions key terms
Essential terms and concepts related to blood transfusion reactions for NCLEX review. This set covers types of reactions, nursing actions, and safety priorities.
Quiz(64 vragen)
1. What is a common early sign of a hemolytic transfusion reaction?
Termen in deze set(64)
Types of Blood Transfusion Reactions(16)
What is an acute hemolytic reaction?
A serious reaction occurring when blood types are mismatched, leading to hemolysis of red blood cells.
Symptoms of febrile non-hemolytic reaction?
Fever, chills, headache, and muscle pain. Common after multiple transfusions.
True or False: Allergic reactions to blood transfusions are rare.
False. They can occur in some patients, often presenting as hives or itching.
What is transfusion-related acute lung injury (TRALI)?
A rare but serious reaction causing acute respiratory distress, usually within 6 hours.
Cause of bacterial contamination reactions?
Bacteria in blood products leading to sepsis. Symptoms include fever, chills, and hypotension.
What is a delayed hemolytic reaction?
A reaction that occurs days to weeks after transfusion, due to immune response against transfused red cells.
Symptoms of a transfusion-associated circulatory overload (TACO)?
Shortness of breath, hypertension, tachycardia, and pulmonary edema. Risk in heart failure patients.
Fill in the blank: _____ reactions are primarily due to recipient antibodies reacting with donor blood cells.
Hemolytic
How to differentiate between TRALI and TACO?
TRALI presents with acute respiratory distress; TACO involves fluid overload symptoms.
True or False: Transfusion reactions only happen with red blood cell transfusions.
False. They can occur with any blood component, including platelets and plasma.
What is a minor allergic reaction?
Mild symptoms like hives. Typically managed with antihistamines and does not require stopping the transfusion.
What is the primary risk factor for febrile non-hemolytic reactions?
Prior blood transfusions. The patient's immune system may react to donor white blood cells.
True or False: All blood transfusion reactions are immediate.
False. Some reactions, like delayed hemolytic reactions, can happen weeks later.
Cause of iron overload due to transfusions?
Repeated blood transfusions can lead to excess iron accumulation, particularly in chronic conditions.
What is a common symptom of mild allergic reactions?
Itching or rash. Usually mild and managed without stopping the transfusion.
What is the main concern with transfusion-related acute lung injury (TRALI)?
It can lead to severe respiratory failure and requires immediate medical intervention.
Signs and Symptoms of Reactions(16)
What is a common sign of hemolytic reaction?
Fever and chills are common signs.
Symptoms of allergic reaction to blood transfusion?
Itching, rash, or hives may occur.
True or False: Fever is always a sign of a transfusion reaction.
False - Fever can occur without a reaction.
Signs of fluid overload from transfusion?
Shortness of breath, increased blood pressure, and edema.
What can cause febrile non-hemolytic transfusion reactions?
Recipient's immune response to donor white blood cells.
Fill in the blank: Anaphylactic reactions may cause _______.
Respiratory distress and hypotension.
Difference between allergic and anaphylactic reactions?
Allergic: mild; Anaphylactic: life-threatening.
Common symptoms of transfusion-related acute lung injury?
Sudden respiratory distress and fever.
What indicates a possible septic reaction?
Fever, chills, and hypotension.
What symptom suggests a hemolytic transfusion reaction?
Back pain, especially at the kidneys.
Signs of a transfusion reaction in older adults?
Confusion, elevated heart rate, and decreased oxygen saturation.
Fill in the blank: A reaction leading to dark urine indicates _______.
Hemolysis of red blood cells.
Common gastrointestinal symptoms of transfusion reactions?
Nausea, vomiting, and diarrhea.
What do hypotension and tachycardia indicate?
Possible severe reaction or shock.
True or False: All transfusion reactions present with fever.
False - Not all reactions involve fever.
What might indicate a delayed transfusion reaction?
Decreased hemoglobin levels days post-transfusion.
Nursing Actions and Interventions(16)
What is the first action if a transfusion reaction occurs?
Stop the transfusion immediately and maintain IV access with normal saline.
True or False: Always notify the healthcare provider after a transfusion reaction.
True - Immediate notification is crucial for patient safety.
What vital signs should be monitored after a reaction?
Monitor temperature, heart rate, respiratory rate, and blood pressure frequently.
Fill in the blank: Administer _______ as ordered for allergic reactions.
antihistamines or corticosteroids.
How should blood product labels be handled?
Verify the patient's identification and blood product at the bedside before administration.
What is a key nursing action for fever during a transfusion?
Administer antipyretics as ordered and monitor patient closely.
Cause → Effect: What happens if you do not stop a transfusion promptly?
Delayed recognition can lead to severe complications or even death.
How to document a transfusion reaction?
Record the time, symptoms, actions taken, and notify healthcare provider.
What is the importance of maintaining IV access?
It allows for rapid administration of emergency medications or fluids.
True or False: You can restart a transfusion after treating a mild reaction.
False - Always check with the provider before considering restarting.
What should be done with the blood product after a reaction?
Return it to the blood bank for further investigation.
Question: What is the role of saline after a transfusion reaction?
Saline helps to flush the IV line and maintain venous access.
Comparison: Transfusion reaction vs. an allergic reaction?
Transfusion reactions are often more severe, while allergies can be mild.
When to notify the blood bank?
Always notify if a transfusion reaction occurs for proper tracking.
What to assess for after administering medications?
Monitor for improvement in symptoms or any adverse effects.
Fill in the blank: Maintain patient ________ during a transfusion reaction.
safety and comfort.
Prevention and Safety Measures(16)
What is the first step before a blood transfusion?
Verify the patient's identity and consent.
True or False: Blood should be warmed before transfusion.
False. Blood should not be warmed in a microwave; use a blood warmer.
What equipment is essential for blood transfusion?
Use an appropriate blood transfusion set with a filter.
Fill in the blank: Always monitor vital signs ______ minutes after starting transfusion.
15 minutes.
What should you do if a transfusion reaction occurs?
Stop the transfusion immediately and notify the physician.
Cause → Effect: What can happen if mismatched blood is transfused?
Acute hemolytic reaction may occur, potentially fatal.
What is the minimum time frame for monitoring post-transfusion?
At least 1 hour after completion.
True or False: You can leave the patient alone during the transfusion.
False. The patient must be monitored continuously.
What is the purpose of using a blood filter?
To remove clots and debris from blood.
How often should vital signs be checked during a transfusion?
Every 15 minutes initially, then per hospital policy.
List two key preventive measures for transfusion reactions.
- Use proper blood type - Ensure proper administration techniques.
What type of environment is necessary for blood storage?
Refrigerated at 1-6°C (34-43°F).
What should be done with blood products if not used within 30 minutes?
Return them to the blood bank.
What does informed consent involve?
Patient understanding of risks, benefits, and alternatives.
Fill in the blank: Always use ____ to identify blood type.
Two person verification.
What is the role of pre-transfusion testing?
To ensure compatibility and reduce reaction risk.
Vragen in deze set(64)
1. What is a common early sign of a hemolytic transfusion reaction?
2. What should a nurse do immediately if a transfusion reaction is suspected?
3. What is the primary characteristic of an acute hemolytic transfusion reaction?
4. What is the first action a nurse should take before administering a blood transfusion?
5. Which symptom is indicative of an allergic reaction to a blood transfusion?
6. Which of the following vital signs should be monitored closely during a transfusion?
7. Which symptom is NOT associated with febrile non-hemolytic transfusion reactions?
8. Which of the following is NOT a recommended practice before a blood transfusion?
9. True or False: A high fever always indicates a transfusion reaction.
10. Fill in the blank: After a transfusion reaction, the nurse should document the ________.
11. What is the main cause of allergic reactions during blood transfusions?
12. During a blood transfusion, when should vital signs be checked initially?
13. Which of the following is a sign of fluid overload due to a blood transfusion?
14. True or False: It's acceptable to restart a transfusion after treating a mild allergic reaction.
15. How quickly can transfusion-related acute lung injury (TRALI) occur after a blood transfusion?
16. If a transfusion reaction occurs, what is the priority action for the nurse?
17. What primarily causes febrile non-hemolytic transfusion reactions?
18. What is the importance of notifying the healthcare provider after a transfusion reaction occurs?
19. Which of the following is a symptom of transfusion-associated circulatory overload (TACO)?
20. What should be done if blood products are not administered within 30 minutes of arrival?
21. Fill in the blank: Anaphylactic reactions to transfusions can lead to _______.
22. What should the nurse assess for after administering antihistamines for an allergic reaction?
23. True or False: A delayed hemolytic reaction can occur weeks after a blood transfusion.
24. Which statement about blood filters is true?
25. What is the main difference between allergic and anaphylactic reactions?
26. Which action is NOT appropriate after a transfusion reaction?
27. What is the most likely cause of bacterial contamination reactions in blood transfusions?
28. How often must a nurse reassess the patient’s vital signs during a transfusion according to hospital policy?
29. Which symptom is most commonly associated with transfusion-related acute lung injury (TRALI)?
30. What role does normal saline play after a transfusion reaction?
31. Which type of reaction involves recipient antibodies attacking transfused red blood cells?
32. What is the purpose of pre-transfusion testing?
33. What combination of symptoms would indicate a possible septic reaction?
34. When should the blood bank be notified during a transfusion reaction?
35. What is the correct management for mild allergic reactions during blood transfusions?
36. Which action is appropriate if a patient has a history of transfusion reactions?
37. What symptom would suggest a hemolytic transfusion reaction during a transfusion?
38. What is a key nursing action for managing fever during a transfusion?
39. Which reaction is characterized by symptoms occurring after multiple transfusions?
40. What is the correct environment for storing blood products?
41. Which signs may indicate a transfusion reaction in older adults?
42. What is the primary reason for verifying patient identification and blood product at the bedside?
43. True or False: Transfusion reactions can only occur with red blood cell transfusions.
44. Which of the following is a key preventive measure for transfusion reactions?
45. Fill in the blank: Dark urine after a transfusion indicates _______.
46. In the context of blood transfusions, what does 'delayed recognition' refer to?
47. Fill in the blank: Symptoms of febrile non-hemolytic reactions often include _____ and muscle pain.
48. Informed consent for a blood transfusion includes understanding of what?
49. What gastrointestinal symptoms might suggest a transfusion reaction?
50. Which of the following describes a key difference between a transfusion reaction and an allergic reaction?
51. Which of the following is a long-term risk associated with repeated blood transfusions?
52. Which statement is TRUE regarding blood product administration?
53. What do hypotension and tachycardia typically indicate following a transfusion?
54. True or False: Maintaining patient safety and comfort during a transfusion reaction is not a priority.
55. What is a key difference between TRALI and TACO?
56. Why is two-person verification necessary in blood transfusion?
57. True or False: Fever is a consistent finding in all transfusion reactions.
58. What is typically the first step in the nursing intervention for a patient experiencing a transfusion reaction?
59. Which symptom is common in both allergic reactions and febrile non-hemolytic reactions?
60. What potential reaction can occur if mismatched blood is transfused?
61. What might suggest a delayed transfusion reaction several days after the transfusion?
62. Which nursing action should be taken if a patient develops hives during a blood transfusion?
63. What is the primary concern with transfusion-related acute lung injury (TRALI)?
64. Which of the following actions is essential for ensuring patient safety before starting a blood transfusion?
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