Blood Transfusion NCLEX Questions with Rationales

Question 1: Pre-Transfusion Assessment

Before beginning a blood transfusion, which assessment is the priority for the nurse to complete?

A. Check the patient’s most recent hemoglobin level
B. Assess baseline vital signs
C. Review the patient’s allergy history
D. Verify the patient has a consent form signed

Correct Answer: B

Rationale: Baseline vital signs are essential before starting any blood transfusion because they provide a comparison point to detect transfusion reactions. Changes in temperature, blood pressure, pulse, and respirations from baseline can indicate a reaction occurring. While all options are important parts of pre-transfusion care, vital signs take priority as they are the primary indicators of adverse reactions during the transfusion process.

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Question 2: Blood Product Verification

Two nurses are verifying a unit of packed red blood cells at the bedside. Which information must be verified? (Select all that apply)

A. Patient’s full name and medical record number
B. Blood unit number matches the requisition
C. Blood type matches the patient’s type
D. Expiration date of the blood product
E. Physician who ordered the transfusion

Correct Answers: A, B, C, D

Rationale: Two licensed nurses must verify the patient’s identity using two identifiers, confirm the blood unit number matches the requisition form, verify blood type compatibility between the unit and the patient, and check the expiration date. This is a critical safety measure to prevent transfusion errors. While knowing which physician ordered the transfusion is part of the chart, it is not part of the bedside verification process.

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Question 3: Temperature Consideration

A patient is scheduled to receive a transfusion of packed red blood cells. The nurse assesses the patient’s temperature as 100.8°F (38.2°C). What is the appropriate nursing action?

A. Begin the transfusion as ordered
B. Administer acetaminophen and start the transfusion
C. Withhold the transfusion and notify the physician
D. Wait 30 minutes and recheck the temperature

Correct Answer: C

Rationale: A temperature above 100°F (37.8°C) should be reported to the physician before starting a transfusion because fever is a sign of a potential transfusion reaction. Starting a transfusion when the patient already has an elevated temperature makes it difficult to determine if subsequent fever is from the transfusion or a pre-existing condition. The physician may order the transfusion to proceed, but this decision must be made by the provider, not the nurse independently.

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Question 4: Transfusion Reaction

During a blood transfusion, the patient develops fever, chills, back pain, and hypotension. What is the nurse’s immediate action?

A. Slow the transfusion rate and monitor closely
B. Stop the transfusion and maintain IV access with normal saline
C. Administer an antihistamine as ordered
D. Continue the transfusion but notify the physician

Correct Answer: B

Rationale: These symptoms indicate an acute hemolytic transfusion reaction, which is a medical emergency. The nurse must immediately stop the transfusion, disconnect the blood tubing from the IV catheter, and keep the vein open with new IV tubing and normal saline 0.9%. This prevents any additional incompatible blood from entering the patient’s circulation. After stopping the transfusion, the nurse should notify the physician, send the blood bag and tubing to the blood bank for testing, and monitor the patient closely.

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Question 5: Blood Administration Equipment

Which IV solution should be used to prime the blood administration tubing?

A. Lactated Ringer’s solution
B. 5% Dextrose in water
C. 0.9% Normal saline
D. 0.45% Normal saline

Correct Answer: C

Rationale: Only 0.9% normal saline (isotonic saline) should be used with blood products. Dextrose solutions cause red blood cell hemolysis (breakdown). Lactated Ringer’s contains calcium, which can cause blood to clot in the tubing. Hypotonic solutions like 0.45% saline can cause cell lysis. Normal saline is compatible with blood and maintains the integrity of red blood cells during transfusion.

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Question 6: Transfusion Initiation

When starting a blood transfusion, the nurse should infuse the blood at what rate during the first 15 minutes?

A. As rapidly as possible
B. Slowly, approximately 50-75 mL per hour
C. At the same rate throughout the transfusion
D. Based on the patient’s blood pressure

Correct Answer: B

Rationale: Blood should be infused slowly during the first 15 minutes (approximately 2 mL/min or 50-75 mL/hour) while the nurse remains with the patient to observe for immediate transfusion reactions. Most severe reactions occur within the first 15 minutes of transfusion. If no adverse reactions occur, the rate can be increased according to the physician’s order. This cautious approach allows for early detection of reactions while minimizing the amount of incompatible blood transfused.

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Question 7: Time Limit for Blood Administration

A unit of packed red blood cells has been infusing for 3 hours. What should the nurse do?

A. Continue the infusion until the unit is complete
B. Slow the infusion rate to complete within 6 hours
C. Discontinue the transfusion and discard remaining blood
D. Speed up the infusion to finish within 4 hours

Correct Answer: D

Rationale: Blood products must be completed within 4 hours of starting the transfusion to prevent bacterial growth at room temperature and minimize the risk of septicemia. If a transfusion cannot be completed within 4 hours, the rate should be increased if the patient can tolerate it, or the transfusion should be discontinued. Blood should never hang longer than 4 hours. At the 3-hour mark, the nurse should assess the remaining volume and adjust the rate appropriately to complete the transfusion safely within the time limit.

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Question 8: Patient History

Before administering a blood transfusion, which question is most important for the nurse to ask the patient?

A. “Have you ever received a blood transfusion before?”
B. “Do you know why you need this transfusion?”
C. “Are you afraid of needles?”
D. “Have you had breakfast today?”

Correct Answer: A

Rationale: Asking about previous transfusion history is essential because patients who have received multiple transfusions are at higher risk for febrile non-hemolytic transfusion reactions and may have developed antibodies. This information helps the nurse establish a baseline for patient teaching and allows for appropriate monitoring. Previous reactions should be clearly documented and communicated to the healthcare team. While the other questions may be relevant, knowing the transfusion history directly impacts patient safety and monitoring priorities.

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Question 9: Blood Type Compatibility

A patient with Type B positive blood needs a transfusion. Which blood types can this patient safely receive? (Select all that apply)

A. B positive
B. B negative
C. O positive
D. O negative
E. AB positive

Correct Answers: A, B, C, D

Rationale: A patient with B positive blood can receive B positive, B negative, O positive, and O negative blood. Type B patients have B antigens and anti-A antibodies, so they can receive B or O blood. Rh positive patients can receive both Rh positive and Rh negative blood. However, they cannot receive Type A or AB blood because the anti-A antibodies would attack the A antigens, causing a hemolytic reaction. Type AB blood contains A antigens, which would be incompatible.

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Question 10: Allergic Transfusion Reaction

A patient receiving a platelet transfusion develops hives, itching, and mild dyspnea 30 minutes into the transfusion. Vital signs remain stable. What is the priority nursing intervention?

A. Continue the transfusion and monitor closely
B. Stop the transfusion and administer antihistamine as ordered
C. Slow the transfusion rate by half
D. Apply oxygen and continue the transfusion

Correct Answer: B

Rationale: These symptoms indicate an allergic transfusion reaction, which is the most common type of transfusion reaction. The appropriate response is to stop the transfusion, maintain IV access with normal saline, and administer antihistamines (such as diphenhydramine) as ordered by the physician. While allergic reactions are typically less severe than hemolytic reactions, they can progress to anaphylaxis. After treatment with antihistamines, the transfusion may be resumed per physician order if symptoms resolve.

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Question 11: Febrile Transfusion Reaction

Which patient is at highest risk for developing a febrile non-hemolytic transfusion reaction?

A. A first-time transfusion recipient
B. A patient who has received multiple transfusions in the past
C. A patient with Type O negative blood
D. A patient with a low platelet count

Correct Answer: B

Rationale: Febrile non-hemolytic transfusion reactions occur when the recipient’s white blood cell antibodies react against donor white blood cells in the transfused blood. Patients who have received multiple transfusions or women who have been pregnant are at higher risk because they have been exposed to foreign antigens and developed antibodies. These reactions present with fever and chills but are not life-threatening. The treatment includes stopping the transfusion, administering antipyretics, and notifying the physician.

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Question 12: Post-Transfusion Care

After completing a blood transfusion, what should the nurse document?

A. Only the start and stop times
B. Patient tolerance and vital signs throughout transfusion
C. Total volume infused and blood type administered
D. All of the above plus any adverse reactions

Correct Answer: D

Rationale: Complete documentation of blood transfusion must include the start and stop times, type and volume of blood product, vital signs before, during (at 15 minutes and hourly), and after transfusion, patient’s response to the transfusion, any adverse reactions and interventions performed, and patient tolerance of the procedure. This comprehensive documentation is essential for patient safety, legal protection, and continuity of care. Blood transfusion documentation is scrutinized closely due to the high-risk nature of the procedure.

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Question 13: Fresh Frozen Plasma (FFP)

A patient is receiving fresh frozen plasma (FFP). What is the primary purpose of this blood product?

A. Increase hemoglobin and hematocrit levels
B. Provide clotting factors
C. Boost immune system function
D. Replace platelets

Correct Answer: B

Rationale: Fresh frozen plasma contains clotting factors including fibrinogen, prothrombin, and factors V, VII, VIII, IX, X, XI, and XIII. It is primarily used to treat coagulation disorders, reverse warfarin effects, or provide volume expansion in emergency situations. FFP does not significantly increase hemoglobin levels (that’s the role of packed red blood cells) or platelet counts (that’s the role of platelet transfusions). FFP must be ABO-compatible and is typically administered rapidly in emergency situations.

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Question 14: Transfusion Complications

A patient who received a blood transfusion 3 days ago develops jaundice and dark urine. What type of reaction should the nurse suspect?

A. Acute hemolytic reaction
B. Allergic reaction
C. Delayed hemolytic reaction
D. Febrile reaction

Correct Answer: C

Rationale: A delayed hemolytic transfusion reaction occurs days to weeks after transfusion when the recipient develops antibodies that destroy the transfused red blood cells. Symptoms include jaundice, dark urine, fever, and decreased hemoglobin levels. This differs from acute hemolytic reactions, which occur immediately during or shortly after transfusion. Delayed reactions are less severe but require monitoring and treatment. The nurse should notify the physician and monitor hemoglobin levels and renal function.

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Question 15: Massive Transfusion Protocol

A trauma patient is receiving multiple units of packed red blood cells rapidly. Which electrolyte imbalance is the patient most at risk for developing?

A. Hyperkalemia
B. Hypercalcemia
C. Hypernatremia
D. Hypermagnesemia

Correct Answer: A

Rationale: During massive transfusions, stored blood contains high levels of potassium due to red blood cell breakdown during storage. Rapid administration of multiple units can lead to hyperkalemia, which can cause life-threatening cardiac arrhythmias. Additionally, massive transfusions can cause hypocalcemia (not hypercalcemia) due to citrate toxicity from the preservative in stored blood. The nurse must monitor potassium levels closely and watch for ECG changes indicating hyperkalemia.

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Types of Transfusion Reactions

Acute Hemolytic Reaction (Most Serious)

Timing: Within minutes to hours
Cause: ABO incompatibility
Signs/Symptoms: Fever, chills, chest pain, back pain, dyspnea, hypotension, hemoglobinuria
Management: Stop transfusion immediately, maintain IV with NS, notify physician, send blood to lab, monitor renal function

Febrile Non-Hemolytic Reaction (Most Common)

Timing: During or within 4 hours
Cause: Recipient antibodies against donor WBCs
Signs/Symptoms: Fever (>1°C rise), chills, headache
Management: Stop transfusion, antipyretics, rule out hemolytic reaction

Allergic Reaction

Timing: During or shortly after transfusion
Cause: Recipient sensitivity to donor plasma proteins
Signs/Symptoms: Hives, itching, flushing, mild dyspnea
Management: Stop transfusion, antihistamines, may resume after treatment

Anaphylactic Reaction

Timing: Within minutes
Cause: IgA deficiency in recipient
Signs/Symptoms: Severe hypotension, bronchospasm, respiratory distress, shock
Management: Stop transfusion, epinephrine, emergency response, do not restart

Circulatory Overload (TACO)

Timing: During or within 6 hours
Cause: Too rapid infusion or excessive volume
Signs/Symptoms: Dyspnea, crackles, jugular venous distention, hypertension
Management: Stop transfusion, elevate head of bed, oxygen, diuretics

Septic Reaction

Timing: During or shortly after
Cause: Bacterial contamination of blood product
Signs/Symptoms: High fever, severe chills, hypotension, shock
Management: Stop transfusion, broad-spectrum antibiotics, blood cultures

Critical Nursing Interventions for Blood Transfusions

Before Transfusion:

1. Verify physician order and obtain informed consent
2. Assess baseline vital signs
3. Check patient history for previous transfusions or reactions
4. Verify patient identity using two identifiers
5. Establish IV access with 18-20 gauge catheter
6. Obtain blood from blood bank (transfuse within 30 minutes)
7. Verify blood product with two nurses at bedside

During Transfusion:

1. Use blood administration set with filter
2. Prime tubing with 0.9% normal saline only
3. Start infusion slowly (2 mL/min for first 15 minutes)
4. Remain with patient for first 15 minutes
5. Assess vital signs: baseline, 15 minutes, then hourly
6. Monitor for signs of transfusion reactions
7. Complete transfusion within 4 hours

After Transfusion:

1. Flush tubing with normal saline
2. Monitor vital signs and patient response
3. Document complete transfusion record
4. Return blood bag and tubing to blood bank per policy
5. Assess effectiveness through lab values

Patient Education for Blood Transfusions

Before Transfusion:

• Explain the purpose and procedure
• Discuss potential risks and benefits
• Obtain informed consent
• Encourage questions and address concerns
• Inform patient to report any unusual symptoms immediately

Symptoms to Report:

• Fever or chills
• Chest pain or back pain
• Difficulty breathing or shortness of breath
• Itching, rash, or hives
• Dizziness or feeling faint
• Nausea or vomiting
• Rapid heart rate
• Any unusual sensations

Post-Transfusion Care:

• Monitor for delayed reactions (up to several weeks)
• Report dark urine or jaundice
• Follow up with laboratory tests as ordered
• Understand signs of infection
• Keep a record of transfusions received

Special Considerations

Pediatric Transfusions:

• Use smaller blood volumes (10-15 mL/kg)
• Infuse more slowly to prevent circulatory overload
• Monitor closely for volume overload
• Use appropriate size IV catheter (22-24 gauge)
• Involve parents in monitoring and education

Geriatric Transfusions:

• Higher risk for circulatory overload due to decreased cardiac reserve
• May need slower infusion rates
• Monitor respiratory status closely
• Consider premedication with diuretics in some cases
• Watch for signs of heart failure

Patients with Multiple Transfusions:

• Higher risk for febrile reactions
• May require leukocyte-reduced blood products
• Monitor for iron overload with chronic transfusions
• Increased antibody formation risk
• May need premedication before transfusions

Religious and Cultural Considerations:

• Some patients (Jehovah’s Witnesses) refuse blood products
• Respect patient’s religious beliefs and autonomy
• Discuss alternative treatments with physician
• Document patient refusal appropriately
• Consider bloodless surgery techniques when possible

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NCLEX Test-Taking Strategies for Blood Transfusion Questions

1. Safety First: Always prioritize stopping the transfusion if a reaction is suspected
2. Two-Nurse Verification: Remember that blood products require verification by two licensed nurses
3. Time Limits: Blood must be started within 30 minutes of leaving blood bank and completed within 4 hours
4. Normal Saline Only: Never use dextrose or other solutions with blood products
5. First 15 Minutes: Most serious reactions occur in first 15 minutes – stay with patient
6. Vital Signs: Always check baseline vitals before starting transfusion
7. ABO Compatibility: Know which blood types can receive which types

Common NCLEX Pitfalls to Avoid

• Confusing blood type compatibility – Remember O negative is universal donor, AB positive is universal recipient
• Forgetting the 4-hour rule – Blood must be completed within 4 hours
• Using wrong IV solution – Only 0.9% normal saline is compatible with blood
• Not stopping transfusion immediately when reaction suspected – always stop first, then assess
• Mixing up reaction types – Know the timing and symptoms of each type
• Forgetting two-nurse verification – This is a critical safety step that cannot be skipped
• Not staying with patient during first 15 minutes of transfusion

Laboratory Values to Monitor

Before Transfusion:

• Hemoglobin: Normal 12-16 g/dL (females), 14-18 g/dL (males)
• Hematocrit: Normal 37-47% (females), 42-52% (males)
• Platelet Count: Normal 150,000-400,000/mm³
• Type and Crossmatch: Must be current (typically within 72 hours)
• PT/INR and aPTT: For patients receiving FFP

After Transfusion:

• Hemoglobin should increase approximately 1 g/dL per unit PRBC
• Hematocrit should increase approximately 3% per unit PRBC
• Platelet count should increase 30,000-60,000/mm³ per unit
• Monitor for signs of hemolysis (elevated bilirubin, decreased haptoglobin)

Medication Considerations

Medications That May Be Given:

• Antihistamines (Diphenhydramine): For allergic reactions or prophylaxis
• Antipyretics (Acetaminophen): For febrile reactions or prophylaxis
• Diuretics (Furosemide): To prevent circulatory overload in at-risk patients
• Epinephrine: For anaphylactic reactions

Important Rules:

• NEVER add medications to blood products
• NEVER give medications through blood transfusion tubing
• Use a separate IV line for medications
• Premedication may be ordered for patients with history of reactions

Blood Product Storage and Handling

Storage Requirements:

• PRBCs: Refrigerated at 1-6°C (33.8-42.8°F)
• FFP: Frozen at -18°C (0°F) or colder; thawed before use
• Platelets: Room temperature (20-24°C) with constant agitation
• Whole Blood: Refrigerated at 1-6°C

Critical Safety Points:

• Blood must be picked up from blood bank immediately before transfusion
• Never store blood in medication refrigerators
• Inspect blood for clots, discoloration, or gas bubbles
• If blood is not started within 30 minutes, return to blood bank
• Do not warm blood in microwave or hot water – use blood warmer only

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Emergency Situations Requiring Blood Transfusions

Acute Blood Loss:

• Trauma patients
• Surgical hemorrhage
• Gastrointestinal bleeding
• Postpartum hemorrhage
• Priority: Rapid volume replacement, may use O negative blood in emergencies

Severe Anemia:

• Hemoglobin <7 g/dL with symptoms
• Sickle cell crisis
• Bone marrow failure
• Priority: Gradual replacement to avoid circulatory overload

Coagulation Disorders:

• Disseminated intravascular coagulation (DIC)
• Massive transfusion protocol
• Liver disease with bleeding
• Priority: Replace specific clotting factors with FFP or cryoprecipitate

Autologous Transfusions

Some patients donate their own blood before scheduled surgery (autologous donation). Benefits include:

• Eliminates risk of disease transmission
• Eliminates risk of incompatibility reactions
• Reduces demand on blood supply
• Acceptable to some religious groups

Nursing Considerations:

• Blood still requires proper verification
• Must be labeled clearly as autologous
• Same time limits apply (complete within 4 hours)
• Monitor for reactions (though rare with autologous blood)

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Quality Improvement and Error Prevention

Root Causes of Transfusion Errors:

1. Failure to properly identify patient
2. Mislabeling of blood samples
3. Failure to verify blood product at bedside
4. Communication breakdowns
5. Rushing the verification process

Prevention Strategies:

• Always use two patient identifiers
• Never skip the two-nurse verification
• Use barcode scanning when available
• Follow institutional protocols exactly
• Report near-misses to improve systems
• Participate in ongoing education

Practice Question Summary Tips

When answering NCLEX questions about blood transfusions, remember these key points:

1. Patient Safety is Priority #1: If you suspect any reaction, stop the transfusion immediately
2. Verification Cannot Be Rushed: Two nurses, two identifiers, check everything
3. Time is Critical: Know the 30-minute and 4-hour rules
4. Solutions Matter: Only normal saline 0.9% with blood products
5. Reactions Have Patterns: Know the timing, symptoms, and interventions for each type
6. Documentation is Essential: Record everything thoroughly
7. Patient Education Empowers: Teach patients what to report

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Conclusion

Mastering blood transfusion concepts is essential for both NCLEX success and safe nursing practice. Understanding blood compatibility, proper administration techniques, recognition of transfusion reactions, and appropriate nursing interventions will help you provide excellent patient care and excel on your examination.

Remember that blood transfusion is a high-risk procedure requiring vigilant monitoring and strict adherence to safety protocols. The two-nurse verification process exists to prevent potentially fatal errors. Always prioritize patient safety by following established protocols, remaining with patients during the critical first 15 minutes, and being prepared to recognize and respond to transfusion reactions immediately.

Practice these questions regularly, understand the rationales behind each answer, and apply critical thinking skills to similar scenarios. Success on NCLEX comes from understanding concepts, not memorizing facts. Focus on the “why” behind each intervention, and you’ll be well-prepared for any blood transfusion question on exam day.

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Disclaimer: This content is for educational purposes only and should not replace clinical judgment or institutional policies. Always follow current NCLEX guidelines, hospital protocols, and physician orders. Consult with your nursing instructors and use official NCLEX review materials for comprehensive exam preparation. Blood transfusion protocols may vary by institution – always follow your facility’s specific policies and procedures.