1. Nurse has just received a bag of packed red blood cells (RBCs) for a patient.

What is the longest time the nurse can let the blood infuse?

a. 30 minutes

b. 2 hours

c. 4 hours

d. 6 hours

ANS: C

Ideally a unit of whole blood or packed RBCs is transfused in 2 hours. This time

can be lengthened to 4 hours if the patient is at risk for extracellular volume

excess. Beyond 4 hours there is a risk for bacterial contamination of the blood.

1. patient has an acute intravascular hemolytic reaction to a blood transfusion.

After discontinuing the blood transfusion, which isthe nurse’s next action?

a. Discontinue the IV catheter.

b. Return the blood to the blood bank.

c. Run normal saline through the existing tubing.

d. Start normal saline at TKO rate using new tubing.

ANS: D

The nurse should first attach new tubing and begin running in normal saline at a

rate to keep the vein open, in case any medications need to be delivered through

an IV site. The existing tubing should not be used because

that would infuse the blood in the tubing into the patient. It is necessary to

preserve the IV catheter in place for IV access to treat the patient. After the

patient has been assessed and stabilized, the blood can be returned to the blood

bank.

38.A nurse is assessing a patient who is receiving a blood transfusion and

finds that the patient is anxiously fidgeting in bed. The patient is afebrile and

dyspneic. The nurse auscultates crackles in both lung bases and sees jugular

vein distention. On which transfusion complication will the nurse focus

interventions?