Submitted by

[Osborn] chapter 23
Learning Outcomes [Number and Title ]
Learning Outcome 1
Describe the rationale for blood donation requirements and
restrictions.
Learning Outcome 2
Describe the advantages of blood component therapy and the
therapeutic uses for each component.
Learning Outcome 3
Compare and contrast the hazards of transfusion therapy and
the nursing measures used to assess and prevent them.
Learning Outcome 4
Using the nursing process, describe the administration
procedure for blood administration.
Learning Outcome 5
Delineate the critical thinking and clinical judgment nursing
skills necessary to appropriately treat adverse reactions to
blood transfusions.

Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation for
Practice Copyright 2010 by Pearson Education, Inc.

Submitted by
1. What is the purpose of checking the temperature, pulse, blood pressure, and weight of
a potential blood donor?
Select all that apply.
1.
2.
3.
4.

Individuals with a fever are not used due to the risk of infection
Individuals with a high blood pressure are not permitted to donate blood.
Individuals with a very high pulse are not permitted to donate blood.
Individuals with a very low pulse rate (with the exception of highly
conditioned athletes) are not permitted to donate blood.
5. Individuals with an irregular heartbeat are not permitted to donate blood.
Correct Answer:
1. Individuals with a fever are not used due to the risk of infection
2. Individuals with a high blood pressure are not permitted to donate blood.
3. Individuals with a very high pulse are not permitted to donate blood.
4. Individuals with a very low pulse rate (with the exception of highly
conditioned athletes), are not permitted to donate blood.
5. Individuals with an irregular heartbeat are not permitted to donate blood.
Rationale:
Individuals with a fever are not used due to the risk of infection. A fever possibly
indicates the presence of infection, which increases the risk of transmitting it to the
recipient. Individuals with a high blood pressure are not permitted to donate
blood. There is too big of a physiological risk to the donor to take the blood.
Individuals with a very high pulse are not permitted to donate blood. There is too
big of a risk of altered tissue perfusion for the donor to take the blood. Individuals
with a very low pulse rate (with the exception of highly conditioned athletes) are
not permitted to donate blood. Unless the potential donor is a seasoned athlete,
there is too big of a risk of altered tissue perfusion for the donor to take the blood.
Individuals with an irregular heartbeat are not permitted to donate blood. There
is too big of a risk of altered tissue perfusion for the donor to take the blood.
Cognitive Level: Analyzing
Nursing Process: Assessment
Client Need: Safe, Effective Care Environment
LO: 1

Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation for
Practice Copyright 2010 by Pearson Education, Inc.

Submitted by
2. You are interviewing a potential blood donor, and you ask the individual how much she
weighs. What is the purpose of this question?
1. National guidelines dictate that the donors body weight must be greater
than 50 kg (110 lb) to donate 450 mL of blood.
2. The donors body weight determines how rapidly the blood can be taken
from the donor.
3. The donors body weight helps determine the presence of an infection.
4. The donors body weight determines how long the individual must remain
lying down after the blood donation.
Correct Answer: National guidelines dictate that the donors body weight must be greater
than 50 kg (110 lb) to donate 450 mL of blood.
Rationale:
Weight must be greater than 50 kg (110 lb) to donate 450 mL of blood. This is a national
guideline put forth by the American Red Cross. The donors weight determines how
much blood can be taken, not how fast it can be taken. There is not correlation of weight
to rates of infection. Body weight is not related to length of time needed to rest after
blood donation.
Cognitive Level: Applying
Nursing Process: Implementation
Client Need: Physiological Integrity
LO: 1

Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation for
Practice Copyright 2010 by Pearson Education, Inc.

Submitted by
3. You are the nurse interviewing a potential blood donor. You ask the client what
medications he uses (prescription, over the counter, blood thinners, recent immunization,
and illicit). What is the purpose of this question?
1. Medications can pass from blood donor to recipient in the donated blood.
2. To educate the blood donor about risks associated with illicit drug use.
3. The physician at the blood bank must be notified of all drug use in
potential donors.
4. A list of medications will be placed on the bag of donated blood.
Correct Answer: Medications can pass from blood donor to recipient in the donated
blood.
Rationale: Medications are present in the bloodstream for defined periods of time after
injection; therefore, they can be passed to the recipient in a blood transfusion.
Educating the blood donor about risks associated with illicit drug use is not the
purpose of the question. Notifying the health care provider at the blood bank of all
drug use in potential donors is not a standard procedure. Placing a list of
medications on the bag of donated blood is not a standard procedure at blood
banks.
Cognitive Level: Applying
Nursing Process: Implementation
Client Need: Safe, Effective Care Environment
LO: 1
4. The client is asking why the doctor ordered only red blood cells (packed RBCs) instead
of the entire unit of whole blood. The nurse explains that:
1. It is an optimal method of transfusing only the specific component needed
by the client.
2. It is the only blood that is left in the blood bank.
3. RBCs are useful for clients who are experiencing a lack of clotting factors.
4. RBCs are useful for preventing transfusion reactions.
Correct Answer: It is an optimal method of transfusing only the specific component
needed by the client.
Rationale: Using only the component that is needed is a safe and economical use of the
blood supply. Using the only blood that is left in the blood bank would never be
the rationale for a blood transfusion. Cryoprecipitates, plasma, and platelets are
used for replacing clotting factors. RBCs cannot prevent a transfusion reaction.
Cognitive Level: Creating

Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation for
Practice Copyright 2010 by Pearson Education, Inc.

Submitted by
Nursing Process: Implementation
Client Need: Health Promotion and Maintenance
LO: 2

Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation for
Practice Copyright 2010 by Pearson Education, Inc.

Submitted by
5. The nurse is caring for an 80-year-old client who is receiving a unit of whole blood.
The nurse understands that he must monitor this client for:
1. Fluid overload.
2. Infection.
3. Liver failure.
4. Thrombosis.
Correct Answer: Fluid overload.
Rationale: High-risk clients for fluid overload are the elderly and those individuals who
already have increased circulatory volume or who have a history of heart failure.
Whole blood contains the most volume, and therefore it has the highest risk of
fluid overload. The clinical manifestations of bacterial contamination may not
occur until the transfusion is complete, or in some instances several hours later,
depending on the virulence of the infecting organism. Liver failure is not
associated with blood transfusions. Increased risk for thrombosis is not associated
with blood transfusions.
Cognitive Level: Analyzing
Nursing Process: Assessment
Client Need: Safe, Effective Care Environment
LO: 2

Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation for
Practice Copyright 2010 by Pearson Education, Inc.

Submitted by
6. What are the advantages of blood component therapy as a method of transfusion?
Select all that apply.
1. It is more economical to separate blood into its component parts.
2. It is safer to use only that portion needed by the client for a specific
condition or disease.
3. It conserves the blood resources, because one unit can be used for multiple
recipients.
4. It decreases volume overload.
5. It reduces side effects and complications.
Correct Answer:
1. It is more economical to separate blood into its component parts.
2. It is safer to use only that portion needed by the client for a specific
condition or disease.
3. It conserves the blood resources, because one unit can be used for multiple
recipients.
4. It decreases volume overload
5. It reduces side effects and complications.
Rationale: It is more economical to separate blood into its component parts. Clients
seldom require all of the components of whole blood; therefore, blood component
therapy is more appropriate and economical. Blood is separated into its
component parts, and only that portion needed by the client for a specific
condition or disease is given. It is safer to use only that portion needed by the
client for a specific condition or disease. The client receives only the needed
components, thereby decreasing volume overload and reducing side effects and
complications. It conserves the blood resources, because one unit can be used
for multiple recipients. Up to six recipients can benefit from one unit of whole
blood, thereby conserving blood resources. Blood is fractioned into component
parts by either a centrifuge or a cell separator. Each component is then processed
and stored appropriately, so as to maximize longevity and cell viability. It
decreases volume overload. By giving only the needed component, the volume is
decreased. For example, giving packed RBCs instead of whole blood decreases
the volume by approximately 50%. It reduces side effects and complications.
There are more side effects associated with certain cells from the donor. By
removing these cells, it decreases the side effects and complications.
Cognitive Level: Applying
Nursing Process: Implementation
Client Need: Safe, Effective Care Environment
LO: 2

Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation for
Practice Copyright 2010 by Pearson Education, Inc.

Submitted by
7. You are caring for a client who was admitted 14 hours ago following a motorcycle
accident. The client has received 20 units of blood due to massive hemorrhage.
You understand that you need to assess this client for:
Select all that apply.
1.
2.
3.
4.
5.

Elevated blood ammonia titers.

Coagulation imbalances.
Hypocalcemia.
Acidbase imbalance.
Hyperkalemia.

Correct Answer:
1. Elevated blood ammonia titers.
2. Coagulation imbalances.
3. Hypocalcemia.
4. Acidbase imbalance.
5. Hyperkalemia.
Rationale: Elevated blood ammonia titers. Clients who have repeated exposure to blood
products and the preservatives used to store blood products have an increased risk
of developing elevated blood ammonia titers. Coagulation imbalances. Clients
who have repeated exposure to blood products and the preservatives used to store
blood products have an increased risk of developing coagulation imbalances.
Hypocalcemia. Clients who have repeated exposure to blood products and the
preservatives used to store blood products have an increased risk of developing
hypocalcemia. Acidbase imbalance. Clients who have repeated exposure to
blood products and the preservatives used to store blood products have an
increased risk of developing acidbase imbalance. Hyperkalemia. Clients who
have repeated exposure to blood products and the preservatives used to store
blood products have an increased risk of developing hyperkalemia.
Cognitive Level: Analyzing
Nursing Process: Assessment
Client Need: Physiological Integrity
LO: 3

Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation for
Practice Copyright 2010 by Pearson Education, Inc.

Submitted by
8. The nurse understands that the osmotic makeup of the blood causes fluid to be
mobilized from the interstitial space, which increases the risk for:
1. Circulatory overload.
2. Hypovolemia.
3. Infection.
4. Transfusion reaction.
Correct Answer: Circulatory overload.
Rationale: Circulatory overload can occur with transfusions because the increased
osmotic makeup of the blood causes fluid to be mobilized from the interstitial
space, thereby increasing intravascular volume well beyond that given during the
transfusion. High-risk clients include the elderly and those individuals who
already have increased circulatory volume or who have a history of heart failure.
Hypovolemia is not a consideration because the volume is being increased, not
decreased. Infections do not manifest themselves until after the completion of the
transfusion and are not related to the osmolality of the blood. Transfusion
reactions are not associated with the osmotic makeup of the blood.
Cognitive Level: Applying
Nursing Process: Implementation
Client Need: Physiological Integrity
LO: 3

Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation for
Practice Copyright 2010 by Pearson Education, Inc.

Submitted by
9. The nurse is caring for a client who suddenly developed severe respiratory distress 2
hours after a blood transfusion. The health provider is notified and a diagnosis of
transfusion-related acute lung injury (TRALI) is made. The nurse understands that this
client may:
1. Never have another transfusion from the same donor.
2. Never have another transfusion again from any donor.
3. Have transfusions again because the donor did not precipitate this event.
4. Have family members who cannot ever have transfusions.
Correct Answer: Never have another transfusion from the same donor.
Rationale: The exact cause of this complication is not fully understood. One prevailing
theory is that TRALI is thought to be caused by the presence of granulocyte
antibodies and biologically active lipids in the donor plasma that the recipient
reacts to. If antibodies are present in the donors plasma, they stimulate the WBCs
in the recipients blood. Aggregates of WBCs form and occlude the
microvasculature of the lungs. All plasma-containing blood components,
including RBCs, platelets, FFP, and cryoprecipitates, can be a cause of TRALI.
Once TRALI has occurred, the recipient should not receive any more transfusions
from the same donor. Transfusion from other donors poses no increased risk.
It is acceptable to have another transfusion from another donor. Family members should
be informed, but it is not an indication for them to not have transfusions
Cognitive Level: Applying
Nursing Process: Implementation
Client Need: Physiological Integrity
LO: 3

Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation for
Practice Copyright 2010 by Pearson Education, Inc.

Submitted by
10. The policy and procedure for blood administration calls for giving no more than 30
mLs in the first 15 minutes. To give that much through tubing with 10 gtts/mL, what
would the drip rate be?
1.
2.
3.
4.

20 gtts/min
5 gtts/min
12 gtts/min
60 gtts/min

Correct Answer: 20 gtts/min

Rationale: If the client is to receive 30 mLs in 15 minutes, that would be 2 mLs per
minute. At 10 gtts per mL, that would be 20 gtts per minute. The other amounts are
incorrectly calculated.
Cognitive Level: Applying
Nursing Process: Implementation
Client Need: Safe, Effective Care Environment
LO: 4

Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation for
Practice Copyright 2010 by Pearson Education, Inc.

Submitted by
11. Which statement made by the client would indicate further teaching is necessary
about blood transfusions?
1. There is no risk of a disease being transmitted through the transfusion
of someone elses blood.
2. There is a period of time when HIV-contaminated blood will test
negative.
3. There is still some risk of contracting hepatitis B through a blood
transfusion.
4. There is still some risk of contracting hepatitis C through a blood
transfusion.
Correct Answer: There is no risk of a disease being transmitted through the transfusion of
someone elses blood.
Rationale: It is not true that there is no risk of disease transmission from a blood
transfusion. This client needs further education. The other statements are correct
and do not require further teaching.
Cognitive Level: Analyzing
Nursing Process: Implementation
Client Need: Health Promotion and Maintenance
LO: 4

Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation for
Practice Copyright 2010 by Pearson Education, Inc.

Submitted by
12. The nurse is caring for a client who was admitted 5 hours ago after sustaining
multiple gunshot wounds to the abdomen. The client has had 8 units of blood. The blood
bank notified the nurse that it was short of blood. The nurse understands that the client
can receive any type of blood if she has ____ blood type.
1. AB
2. A
3. B
4. O
Correct Answer: AB
Rationale: The person with blood type A has B antibodies; someone with type B has A
antibodies; someone with type AB has no antibodies; and a person who has type
O blood has both antibodies. Therefore, the person with type AB blood can
receive any type of blood in an emergency situation and is referred to as the
universal recipient. A person with the O blood type is considered a universal
donor in an emergency situation.
Cognitive Level: Analyzing
Nursing Process: Implementation
Client Need: Safe, Effective Care Environment
LO: 4

Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation for
Practice Copyright 2010 by Pearson Education, Inc.

Submitted by
13. A unit of packed red blood cells was ordered for a client. Twenty minutes after the
blood began infusing, the client developed dyspnea, chest pain, bloody urine, and a
decrease in blood pressure. This type of transfusion reaction is:
1.
2.
3.
4.

Acute hemolytic reaction.

Allergic reaction.
Delayed hemolytic reaction.
Febrile nonhemolytic reaction.

Correct Answer: Acute hemolytic reaction.

Rationale: Bloody urine and decreased urine output, petechiae, jaundice, decreased blood
pressure, chest tightness, low back pain, nausea, anxiety, dyspnea, hypotension,
bronchospasm, hemoglobinemia, acute renal failure, shock, cardiac arrest, and death are
symptoms that typically occur within the first 15 minutes of the transfusion with an acute
hemolytic reaction. Allergic reactions are manifested by itching, hives, flushing, and
chills. Delayed hemolytic reactions are manifested by fever, anemia, increased bilirubin
level, decreased or absent haptoglobin, and jaundice. Febrile nonhemolytic reactions are
manifested by increased pulse rate, temperature > 1oC, chills, headache, nausea and
vomiting, anxiety, flushing, back pain, and muscle aches.
Cognitive Level: Analyzing
Nursing Process: Implementation
Client Need: Physiological Integrity
LO: 5

Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation for
Practice Copyright 2010 by Pearson Education, Inc.

Submitted by
14. Which of the following cause an acute hemolytic transfusion reaction?
Select all that apply.
1. Nurses error when checking the blood
2. ABO incompatibility of the donor and recipient
3. WBC incompatibility
4. Recipients sensitivity to foreign plasma proteins
5. Contaminated blood
Correct Answer:
1. Nurses error when checking the blood
2. ABO incompatibility of the donor and recipient
Rationale: Nurses error when checking the blood. Acute hemolytic reactions may be
due to a mistake in labeling by the laboratory or blood bank or nursing error. ABO
incompatibility of the blood and recipient. This is the physiological reason for the
transfusion reaction. WBC incompatibility. WBC incompatibility causes febrile
nonhemolytic reactions. Recipients sensitivity to foreign plasma proteins. Recipient
sensitivity to foreign plasma proteins causes allergic reactions. Contaminated blood.
Contaminated blood causes infections, not transfusion reactions.
Cognitive Level: Analyzing
Nursing Process: Assessment
Client Need: Physiological Integrity
LO: 5

Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation for
Practice Copyright 2010 by Pearson Education, Inc.

Submitted by
15. Why is the nursing diagnosis of Risk of Injury related to blood transfusions?
Select all that apply.
1.
2.
3.
4.
5.

Risk of transfusion reactions

Risk of disease transmission
Risk of fluid overload
Risk of transfusion-related lung injury
Risk of iron overload

Correct Answer:
1.
2.
3.
4.
5.

Risk of transfusion reactions

Risk of disease transmission
Risk of fluid overload
Risk of transfusion-related lung injury
Risk of iron overload

Rationale: Risk of transfusion reactions. When a client is receiving a blood transfusion,

there are risks involved, including risk of transfusion reactions. That is why Risk for
Injury is an appropriate nursing diagnosis. Risk of disease transmission. When a client
is receiving a blood transfusion, there are risks involved, including risk of disease
transmission. That is why Risk for Injury is an appropriate nursing diagnosis. Risk of
fluid overload. When a client is receiving a blood transfusion, there are risks involved,
including risk of fluid overload. That is why Risk for Injury is an appropriate nursing
diagnosis. Risk of transfusion-related lung injury. When a client is receiving a blood
transfusion, there are risks involved, including risk of transfusion-related lung injury.
That is why Risk for Injury is an appropriate nursing diagnosis. Risk of iron overload.
When a client is receiving a blood transfusion, there are risks involved, including risk of
iron overload. That is why Risk for Injury is an appropriate nursing diagnosis.
Cognitive Level: Applying
Nursing Process: Assessment
Client Need: Physiological Integrity
LO: 5

Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation for
Practice Copyright 2010 by Pearson Education, Inc.