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Answer Key for Blood Therapy 2

Correct answer: d
Rationale: An individual with type AB+ blood can receive blood from any group (with type AB
being preferable) and can only donate blood to another AB+ type individual.

4. A bus accident occurred in a rural area. Several patients taken to the local hospital required
blood transfusions, which resulted in a decreased supply of whole blood. One patient is blood
type B. The blood bank sends type O- RBCs. What is the nurse’s best action?
a) Return the blood to the blood bank.
b) Administer the type O blood.
c) Begin IV fluids until type B blood is obtained.
d) Complete an incident report.

Correct answer: b
Rationale: It is acceptable to provide group O RBCs to all patients. This often occurs in
emergency situations before blood typing occurs and/or blood banks will often substitute group
O RBCs for other blood types if their supply is low.

5. A patient is Rh(D) positive. The blood bank sends Rh(D) negative RBCs. What is the nurse’s
best action?
a) Send the blood product back to the blood bank because Rh(D) negative RBCs should
not be transfused to Rh(D) positive patients.
b) Ask the patient whether he has every been exposed to Rh(D) negative blood before.
c) Request that unit of AB+ blood be sent for the patient.
d) Use the blood product supplied, because Rh(D) negative RBCs may be safely
transfused to Rh(D) positive patients.

Correct answer: d
Rationale: It is acceptable to transfuse Rh(D) negative RBCs to Rh(D) positive patients.

6. A patient is Rh(D) negative. The blood bank sends Rh(D) positive plasma. What should the
nurse do?
a) Use the blood product supplied, because Rh(D) positive plasma may be safely
transfused to Rh(D) negative patients.
b) Send the blood product back to the blood bank, because Rh(D) positive plasma should
not be transfused to Rh(D) negative patients.
c) Send a sample of the patient’s blood to the blood bank for repeat Rh typing before
administering plasma.
d) Contact the physician for further pretransfusion orders.

Correct answer: a
Rationale: It is acceptable to transfuse Rh(D) positive plasma to Rh(D) negative patients,
because the Rh(D) antigens are associated with RBCs rather than with plasma.

7. Identify the blood component that elevates hematocrit by 3% and hemoglobin by 1 g/dL when
1 unit is administered. (Select all that apply.)
a) Whole blood

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Answer Key for Blood Therapy 3

b) RBCs
c) Platelets
d) Plasma
e) Cryoprecipitate

Correct answer: a, b
Rationale: A unit of whole blood should elevate hematocrit by 3% and hemoglobin by 1g/dL in
non-hemorrhaging adult. A unit of RBCs is expected to raise Hgb/Hct levels same as whole
blood.

8. Identify the blood component that can be stored for up to 5 days at room temperature.
a) Whole blood
b) RBCs
c) Platelets
d) Plasma
e) Cryoprecipitate

Correct answer: c
Rationale: Platelets may be stored up to 5 days at room temperature.

9. Identify the blood component that decreases microvascular bleeding during surgery and does
not require ABO and/or Rh testing.
a) Whole blood
b) RBCs
c) Platelets
d) Plasma
e) Cryoprecipitate

Correct answer: e
Rationale: Cryoprecipitate decreases microvascular bleeding during surgical procedures.
Cryoprecipitate is indicated if the patient is bleeding and the fibrinogen level is below 100
mg/dL.

10. The advantages of using this type of autologous blood donation include: it contains more
viable RBCs than stored blood, it has a normal pH, and it contains more 2,3-DPG than other
types of blood donations.
a) Prepoperative
b) Perioperative
c) Hemodilution
d) Allogenic

Correct answer: b
Rationale: Perioperative blood contains more viable RBCs and 2,3-DPG than stored forms of
blood. In addition, the pH is normal.

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Answer Key for Blood Therapy 4

11. Compatibilites for ABO type of donor and recipient are required for which blood products?
(Select all that apply.)
a) Whole blood
b) RBCs
c) Platelets
d) Plasma

Correct answer: a, b, c, d
Rationale: All of the blood products listed should be blood typed prior to use in order to avoid
life-threatening complications from occurring. Cryoprecipitate and colloid components (such as
albumin) do not require ABO or Rh typing.

Copyright © 2017, Elsevier Inc. All Rights Reserved.

Answer Key for Blood Therapy 5

Lesson 2 Post Test

1. Why might dysrhythmias and a reduction in core body temperature occur in a recently infuse
patient?
a) Due to an air embolism
b) Due to volume overload
c) Due to hypocalcemia
d) Due to the rapid administration of unheated blood products

Correct answer: d
Rationale: Rapid administration of unheated solutions may result in iatrogenic hypothermia. A
patient who has an air embolism will probably experience symptoms related to heart attack or
stroke. A patient who experiences volume overload will probably exhibit shortness of breath and
edema. A patient who has hypocalcemia may experience muscle twitching and numbness of the
extremities, which should resolve as the blood passes through the liver.

2. When administering blood products, large-bore catheters are used for this primary reason.
a) Large-bore catheters prevent blood product hemolysis as the product passes through
the catheter and into the blood stream.
b) Larger catheters allow a more consistent rate of administration than smaller catheters.
c) Large-bore catheters are used, because blood products are viscous.
d) Large-bore catheters are used so that flushing the line before and after blood product
infusion is easier.

Correct answer: a
Rationale: Using a large-bore catheter reduces the risk of blood product hemolysis, especially
when administering RBCs. Although some blood products are viscous and a large-bore catheter
does support faster administration and is easier to flush than a small-bore catheter, protecting
blood products from destruction during administration is the primary reason that large-bore
catheters are used.

3. Identify the needle gauge typically recommended to infuse blood products.

a) 16-gauge needle
b) 18-gauge needle
c) 20-gauge needle
d) 22-gauge needle
3) 24-gauge needle

Correct answer: b
Rationale: An 18-gauge needle is the recommended gauge for planned infusions. A 16-gauge
needle is most often used during major surgery, trauma, and obstetric emergency; although it
may be used to infuse blood products outside of those situations, it is rarely the recommended
gauge during a planned infusion. The 20-gauge needle is recommended for most routine patient
applications. The 22-gauge needle is recommended for elderly and children applications. The 24-
gauge needle is the recommended gauge for pediatric and neonate applications.

Copyright © 2017, Elsevier Inc. All Rights Reserved.

Answer Key for Blood Therapy 6

4. Which blood product places a patient at a higher risk of fluid overload after transfusion?
a) Whole blood
b) RBCs
c) Platelets
d) Leukocyte-poor RBCs
e) Cryoprecipitate

Correct answer: a
Rationale: A unit of whole blood is 450 to 500 mL. Other blood products are substantially less
volume.

5. If a patient develops a skin rash, edema, and wheezing during a blood transfusion, the nurse
should:
a) Discard the blood bag and tubing
b) Slow the rate of the transfusion
c) Stop the transfusion immediately
d) Reassess the patient in 10 minutes

Correct answer: c
Rationale: These are signs of an allergic reaction. Stop the transfusion immediately, and connect
normal saline-primed tubing at VAD to prevent any subsequent blood from infusing from the
tubing.

6. What may happen if Lactated Ringers, electrolytes, or other calcium-containing solutions are
administered concurrently with blood products?
a) Calcium binds to citrate.
b) Electrolyte imbalance occurs due to upsetting the sodium-to-calcium balance.
c) Serum protein concentrations reduce.
d) Hyperchloremic metabolic acidosis occurs.

Correct answer: a
Rationale: Most blood products contain citrate as an anticoagulant. Calcium binds to citrate. For
this reason, it is recommended that blood product administration occur separately from most
other IV fluids (except normal saline).

7. A trauma patient has received 6 units of red blood cells. Plasma and platelets are now
prescribed. The nurse changes the blood administration tubing because:
a) Blood tubing must be changed every 6 units.
b) Plasma is unable to pass through tubing that has previously filtered red blood cells.
c) Platelets should run through tubing different than the tubing used for RBCs.
d) Blood tubing must be changed every hour .

Correct answer: c
Rationale: Fibrin strands and debris in the filter may trap platelets.

8. The initial infusion rate and total infusion time for blood products are:

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Answer Key for Blood Therapy 7

a) 5 mL/min; 30 minutes
b) 10 mL/min; 2 hours
c) 30 mL/min; 4 hours
d) 2 mL/min; 4 hours

Correct answer: d
Rationale: The infusion rate is 2 mL/min (or 20 gtt/min using macrodrip of 10 gtt/mL) for the
initial 15 minutes. All blood products need to be infused within 4 hours of initiating the
transfusion.

9. Heating a unit of blood products in a microwave and/or under hot water from the tap is
contraindicated because:
a) It destroys the blood product.
b) It makes the blood product too hot to infuse and, as it cools, it coagulates.
c) Preparation of blood products is the blood bank’s responsibility.

Correct answer: a
Rationale: Use of microwaves and/or hot water destroys blood products, because the heat
generated by the microwave or hot water cannot be adequately moderated to protect blood
products from damage.

10. Identify the transfusion reactions that result in immediate cessation of the transfusion. (Select
all that apply.)
a) Hemolytic reaction
b) Allergic reaction
c) TRALI
d) GVHD
e) Nonhemolytic reaction
f) Circulatory overload
g) Hyperkalemia
h) Hypocalcemia
i) Hypothermia

Correct answer: a, b, e
Rationale: Hemolytic, nonhemolytic , and allergic reactions are life-threatening reactions that
require immediate cessation of the transfusion.

11. It is acceptable practice to place blood into refrigerators and/or freezers located in patient
care areas.
True / False

Correct answer: False

Rationale: Standard refrigerators and/or freezers located in patient care areas are unable to
ensure accurate temperature regulation of blood products. For this reason, they should never be
used to store blood products.

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Answer Key for Blood Therapy 8

12. It is acceptable practice to transfuse medications with blood components.

True / False

Correct answer: False

Rationale: The only solution that may be transfused with blood products is normal saline. All
other IV fluids and/or medications should be administered independent from blood product
administration. For example, 5% dextrose or Ringer’s lactate can result in hemolysis and/or
cause coagulation of the donor blood.

Copyright © 2017, Elsevier Inc. All Rights Reserved.

Answer Key for Blood Therapy 9

Lesson 3 Post Test

1. Most life-threatening transfusion reactions result from:

a) Incorrect identification of patients
b) Failure to type and cross-match blood
c) Patient not knowing his blood type
d) Allergic response to a plasma protein in donor’s blood

Correct answer: a
Rationale: Incorrect patient identification and/or incorrect labeling of blood leads to the
administration of incompatible blood and causes life-threatening transfusion reactions.

2. Adverse reactions from blood transfusions usually occur:

a) After the first hour of the transfusion
b) Within the first 15 minutes of the transfusion
c) 1 hours after completion of the transfusion
d) During the last 15 minutes of the transfusion

Correct answer: b
Rationale: This is why the transfusion is started slowly and why it is so important for the nurse
to intensely monitor the patient during the first 15 minutes of the transfusion.

3. The nurse is transfusing a large amount of blood to a trauma patient. The nurse knows to
observe the patient for:
a) Hypotension and cardiac dysrhythmias
b) Headache and muscle pain
c) Crackles in the lungs and increased central venous pressure
d) Wheezing and chest pain

Correct answer: a
Rationale: Hypotension and cardiac dysrhythmias are the initial reactions to massive
transfusions.

4. Which transfusion reaction results from administering ABO incompatible blood?

a) Febrile reaction
b) Allergic reaction
c) Hemolytic reaction
d) Graft-versus-host disease

Correct answer: c
Rationale: Administration of the wrong blood type results in a hemolytic reaction and is the
most extreme transfusion reaction that is life threatening.

5. A febrile transfusion reaction typically occurs when the patient’s antibodies react to
transfused:
a) FFP

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Answer Key for Blood Therapy 10

b) RBCs
c) Corticosteroids
d) White blood cells (WBCs)

Correct answer: d
Rationale: A febrile transfusion reaction is caused by a patient’s anti bodies responding to the
antigens present on transfused WBCs or platelets in the donor’s blood.

6. The nurse is preparing to administer a unit of packed red blood cells to a patient with a history
of anemia. Which is the best question the nurse should ask the patient before explaining the
procedure?
a) “Are you a Jehovah’s Witness?”
b) “Have you ever had a blood transfusion before?”
c) “Do you have any allergies?”
d) “Are you aware of the risks associated with receiving a blood transfusion?”

Correct answer: b
Rationale: The best question to ask is “Have you ever had a blood transfusion before?” This
question will elicit information without creating fear before patient teaching.

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Answer Key for Blood Therapy 11

Lesson 4 Post Test

1. Which of the following patients is ineligible for autotransfusion?

a) A trauma patient with bilateral hemothorax and splenic tear with an accumulation of
more than 300 mL of blood in the collection chamber
b) A patient admitted with a lower gastrointestinal bleed with copious amounts of blood
coming from the rectum at a rate equal to or greater than 100 mL/hr
c) A patient who has an orthopedic procedure with a hemoglobin of 8
d) A patient who is recovering from a cardiovascular procedure and who has a hematocrit
of 24

Correct answer: b
Rationale: GI bleeding is probably contaminated with bacteria and would exclude this patient
from receiving autotransfusion.

2. A patient who is receiving an autotransfusion has an estimated blood loss of half of the
patient’s blood volume. The physician has ordered FFP. The nurse correctly understands that the
primary rationale for using FFP is:
a) To increase the hematocrit and hemoglobin levels
b) To provide clotting factors and increase blood volume
c) To replace the loss of platelets and clotting factors
d) To prevent a transfusion reaction to the autologous blood.
.
Correct answer: b
Rationale: FFP is administered because it can be transfused rapidly to replace lost fluid volume
and will provide clotting factors. FFP does not contain platelets, so it will not replace platelet
loss. FFP will not specifically increase the hematocrit and hemoglobin. It is unlikely to have a
transfusion reaction to autologous blood. Furthermore, FFP will not prevent a transfusion
reaction and requires ABO compatibility.

3. When turning a patient who has a right-sided hemothorax, 250 mL of dark blood pours into
the chest tube container. The most important intervention is to:
a) Check the chest tube system to confirm patency, and call for a chest x-ray film
immediately.
b) Assess the patient’s vital signs and emergently transfuse 2 units of packed red blood
cells to treat hypovolemia.
c) Prepare for autotransfusion using a high-pressure, rapid infuser to quickly infuse the
blood.
d) Monitor the patient closely, obtain a blood sample for a hematocrit, and document the
drainage since this is probably old blood.

Correct answer: d
Rationale: The color of the blood indicates that it is possibly old, deoxygenated blood. Running
laboratory tests to ensure that the patient’s hematocrit is stable before taking any other action is
the best course of listed actions.

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Answer Key for Blood Therapy 12

4. Signs of complication during autotransfusion would most likely be manifested as:

a) Hypotension and hives
b) Bradycardia and sudden increase of oral temperature
c) Lower back pain and hypotension
d) Blood oozing from all puncture sites and wounds

Correct answer: d
Rationale: Blood oozing from all breaks within the skin indicates clotting issue. The other signs
and symptoms listed would be complications of an allogenic transfusion.

5. A patient arrives in the emergency department with a stab wound to the upper abdomen.
Which of the following findings contraindicates autotransufsion of pleural blood?
a) Wound 5 hours old
b) Great vessel injury
c) Diaphragmatic disruption
d) Myocardial rupture

Correct answer: a
Rationale: Recall that autotransfused blood must be transfused within 6 hours. If the wound is 5
hours old, clotting factors have probably been active and made the blood non-transfusable.

6. While assessing a 49-year-old, intubated patient, the nurse notes that the patient is pale and
hypotensive and has tachycardia and oliguria. The patient has a hemothorax on the right side and
bilateral femur fractures. His chest tubes have drained 350 mL over the previous 2 hours. The
nurse knows that:
a) This patient is hypovolemic from blood loss and is an appropriate candidate for
autotransfusion.
b) The patient should begin receiving dopamine for his blood pressure, and large amounts
of fluid should be infused to facilitate increased urine output.
c) The patient is hypovolemic and a poor candidate for autotransfsion because of the
increased risk of a transfusion reaction.
d) The patient requires decreased cardiac output to decrease his heart rate and
compensate for hypovolemia.

Correct answer: a
Rationale: The signs and symptoms indicate that this patient is hematologically compromised.
The volume of blood in the chest tubes makes this patient an ideal candidate for autotransfusion.

7. The patient is to have blood dilution (i.e., hemodilution) prior to surgery. The nurse is
assessing the patient’s understanding of the procedure. Which statement, if made by the patient,
indicates that further instruction is needed?
a) “A unit of my blood will be removed before surgery and reinfused at the end of the
operation.”
b) “A unit of my blood will be removed, diluted with IV fluids, and returned during
surgery.”

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Answer Key for Blood Therapy 13

c) “As soon as the blood is withdrawn, I will receive IV fluids ot restore my blood
volume.”
d) “During surgery, I will lose fewer RBCs than I would if I did not have the procedure.”

Correct answer: b
Rationale: The removed blood is not diluted; rather, the blood is drawn from a patient before
surgery, and the patient is immediately given IV fluids to compensate for the amount of blood
removed. Since the number of red blood cells in a person’s circulatory system will have been
diluted, fewer red blood cells will be lost from bleeding during the operation. After surgery, the
patient’s own blood is infused.

8. A patient is to have a perioperative blood collection for autotransfusion. The nurse would
recognize which of the following measures as an unexpected step in the process?
a) Fluid aspirated from the surgical site is mixed with an anticoagulant solution.
b) Care is taken when suctioning blood in order to reduce hemolysis of RBCs.
c) Collected blood is washed and concentrated prior to reinfusion.
d) Blood collected from a drainage tube is transfused unwashed to the patient.

Collect answer: d
Rationale: Blood collected from a drainage tube at the surgical site and transfused either washed
or unwashed to the patient describes postoperative blood collection, not perioperative blood
collection. All other statements correctly describe perioperative blood collection for
autotransfusion.

9. A newly hired nurse is orienting to the orthopedic unit where postoperative blood collection
and autotransfusion commonly occur. Which statement, if made by this new nurse, indicates that
further instruction is necessary?
a) “A hemovac is used to collect the blood for autotransfusion.”
b) “The autotransfusion will end when the bleeding stops or slows significantly.”
c) “Postoperative blood collection may also be performed on postoperative cardiac
patients.”
d) “The amount of salvaged blood is generally small.

Collect answer: a
Rationale: Postoperative collection is used primarily in cardiac and orthopedic surgery.
Autotransfusion is ended when bleeding is stopped or slows significantly. Connecting an
ordinary, self-draining device such as a Hemovac container to the drain line(s) discontinues
autotransfusion. In most cases, the volume of salvaged red blood cells is small.

Module Exam

1. The nurse is inspecting a unit of platelets before administering it to the patient. What should
the nurse expect to see?

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Answer Key for Blood Therapy 14

a) Contains many air bubbles

b) Appears cloudy, light pink in color
c) Contains aggregates of cells
d) Appears cloudy, light green in color

Correct answer: b
Rationale: Air bubbles, clots, or discoloration indicate bacterial contamination or inadequate
anticoagulation of the stored component and are contraindications for transfusion of that product.
Thawed FFP should be yellow, light green, or light orange in color and clear in appearance. A
unit of platelets should appear clear and straw or light pink in color. It is normal for
cryoprecipitate to be cloudy.

2. Match the blood product type to the benefits of transfusing that product.
Correct match:
Red blood cells Given to increase the oxygen-carrying capacity of the
circulatory system due to acute or chronic blood loss
(i.e., anemia)
Whole blood Given to increase the oxygen carrying capacity of the
blood and to replace the volume in a patient who is in
shock
Albumin Given to replace volume after acute loss, especially in
patients who have severe burns and/or who are
developing signs of edema; known as a volume
expander
Platelets Given to prevent and/or control bleeding due to
thrombocytopenia
Plasma Given to correct coagulation deficiencies and/or to
reverse the effects of warfarin
Cryoprecipitate Given to control bleeding by replacing clotting factors

3. A young, female trauma patient, whose identity is unknown, requires an immediate, massive
blood transfusion upon arrival to the emergency department. The nurse should administer:
a) O-negative RBCs
b) Typed and cross-matched blood
c) Type-specific blood
d) O-positive RBCs

Correct answer: a
Rationale: While it is preferable to wait for typing and cross matching to occur, in an
emergency, O- blood can be administered until blood typing and matching can occur. O-negative
blood is desired in the premenopausal, female patient. If this patient were male or a
postmenopausal female, it would be acceptable to use O+ blood in this situation.

Copyright © 2017, Elsevier Inc. All Rights Reserved.

Answer Key for Blood Therapy 15

4. When preparing to administer red blood cells, the nurse notes that lactated Ringer’s solution is
hanging on the patient’s IV pole. Before administering the blood product, the most appropriate
action is to cease administering the lactated Ringer’s solution and flush the line with:
a) Histamine
b) Normal saline solution
c) Heparin
d) Calcium

Correct answer: b
Rationale: It is contraindicated to transfuse any substance that might bind to the citrate in the red
blood cells. By flushing with normal saline, you reduce the likelihood that citrate will bind to the
calcium in the lactated Ringer’s solution.

5. After transfusion of several units of blood, a patient continues to bleed. Anticipate an order to
transfuse:
a) Albumin
b) Platelets
c) Whole blood
d) Red blood cells

Correct answer: b
Rationale: Platelets are transfused when it appears that a clotting issue exists.

6. For a patient with low hemoglobin and hematocrit values, the physician would be expected to
order a transfusion of:
a) FFP
b) Platelets
c) RBCs
d) Clotting factors

Correct answer: c
Rationale: A transfusion of RBCs should increase a patient’s hemoglobin and hematocrit values.

7. On inspection, a unit of blood from the blood bank shows several blood clots clinging to the
bag. The best course of action is:
a) Notify the blood bank.
b) Administer the blood as ordered.
c) Add citrate phosphate dextrose (CPD) to the blood.
d) Shake the bag to break the clots up into smaller pieces.

Correct answer: a
Rationale: The blood bank will need to prepare an alternate bag for transfusion.

8. A patient has a pretransfusion hemoglobin value of 6 g/dL and a hematocrit value of 18%.
Two units of RBCs are transfused. Four hours after the transfusion, the patient’s hemoglobin and
hematocrit values would be expected to be:

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Answer Key for Blood Therapy 16

a) Hemoglobin of 7 g/dL and hematocrit of 26%

b) Hemoglobin of 8 g/dL and hematocrit of 24%
c) Hemoglobin of 9 g/dL and hematocrit of 21%
d) Hemoglobin of 9 g/dL and hematocrit of 26%

Correct answer: b
Rationale: The hemoglobin is expected to increase by 2 g/dL and the hematocrit is expected to
increase by 6% after the transfusion of 2 units.

9. What is the most likely complication of an FFP transfusion?

a) Sepsis
b) Dehydration
c) Fluid overload
d) Thrombocytopenia

Correct answer: c
Rationale: Fluid overload is the most likely complication that can occur as a result of an FFP
transfusion.

10. The patient is receiving a unit of whole blood. The patient complains of pain from his
surgical site. The patient has an order for morphine 2 mg IV push every 1 hour as needed. What
is the nurse’s best action?
a) Administer the morphine IV push in the port closest to the patient of the blood
administration tubing.
b) Wait until the transfusion is complete, and then administer the morphine as ordered.
c) Initiate another IV access, and administer the morphine as ordered.
d) Temporarily stop the blood transfusion, flush the tubing with normal saline, administer
the morphine, and restart the transfusion.

Correct answer: c
Rationale: Never inject medication into the same IV line with a blood component because of the
risk for contaminating the blood product with pathogens and the possibility of incompatibility. A
separate IV access must be maintained if the patient requires an IV infusion (i.e., total parenteral
nutrition, pain control) during the transfusion.

11. The nurse is initiating a blood transfusion of packed RBCs. At what rate should the infusion
initially be set?
a) 2 mL/min
b) 10 mL/min
c) 15 mL/min
d) 20 mL/min

Correct answer: a
Rationale: The initial flow rate during the first 15 minutes of a transfusion should be 2 mL/min
or 20 gtt/min (using a macrodrip of 10 gtt/mL). Then regulate to the physician’s orders.

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Answer Key for Blood Therapy 17

12. The nurse initiates a blood transfusion of packed RBCs at 0800. The unit of blood should not
hang beyond:
a) 1000
b) 1200
c) 1400
d) 2000

Correct answer: b
Rationale: A blood transfusion should be completed within 4 hours to reduce the risk of
bacterial growth.

13. The nurse obtains the patient’s vital signs before initiating a blood transfusion. The patient’s
vital signs are B/P 114/78, T 100.3° F, P 88 beats, R 20. What is the nurse’s most appropriate
action?
a) Record the vital signs and initiate the blood therapy slowly.
b) Notify the health care provider of the pretransfusion vital signs.
c) Continue to monitor the patient’s vital signs and, if the patient’s temperature is greater
than 101° F, administer antipyretic.
d) Administer antipyretic and antihistamine, and initiate the transfusion.

Correct answer: b
Rationale: If the patient is febrile ( temperature becomes greater than 100° F [37.8° C]), notify
the physician or health care provider before initiating the transfusion.

14. The nurse initiates a blood transfusion at 0800. When would an acute hemolytic transfusion
most likely occur?
a) By 0815
b) By 0830
c) 2 to 4 hours after completion
d) 2 to 14 days after completion

Correct answer: a
Rationale: Most transfusion reactions occur within the first 15 minutes of the transfusion.

15. A patient who is classified as a universal recipient has what blood type?
a) O-negative
b) O-positive
c) AB-negative
d) AB-positive

Correct answer: d
Rationale: A person with AB-positive blood can receive A+, A-, B+, B-, O+, O-, AB+, and AB-
type blood, and is referred to as the universal recipient.

Copyright © 2017, Elsevier Inc. All Rights Reserved.

Answer Key for Blood Therapy 18

16. The nurse checks the physician’s orders to determine whether there are any pretransfusion
medications to be administered. Which of the following would the nurse most likely expect to
administer?
a) Analgesic (e.g., morphine sulfate)
b) Antibiotic (e.g., ciprofloxacin)
c) Antihistamine (e.g., diphenhydramine)
d) Diuretic (e.g,. furosemide)

Correct answer: c
Rationale: Premedications such as antihistamine or antipyretic may be ordered especially if the
patient demonstrated previous transfusion sensitivity.

17. The nurse is preparing to infuse a blood transfusion rapidly for a patient who is experienced
significant blood loss in a motor vehicle accident. Which gauge of IV cannula would be best for
the nurse to choose?
a) 18 to 20 gauge
b) 22 to 24 gauge
c) 26 gauge
d) 28 gauge

Correct answer: a
Rationale: Large-gauge cannulas (18- or 20-gauge) promote rapid flow of blood components
and are preferred in emergency situations.

18. The nurse initiates a blood transfusion and monitors the patient for signs of a transfusion
reaction. Five minutes into the transfusion, which would be a cause for concern?
a) Temperature is 98.6° F.
b) Patient complains of flank pain and chills.
c) Systolic blood pressure increased by 4 mm Hg from baseline.
d) Patient complains of feeling tired and sleepy.

Correct answer: b
Rationale: Flank pain and chills are signs of an acute hemolytic reaction. The patient may also
complain of chest pain, dyspnea, and pain along the vein receiving blood. The patient is likely to
be hypotensive and tachycardic. Fatigue is a symptom that often accompanies anemia.

19. The nurse is instructing the NAP on signs that a person is having an adverse reaction to a
transfusion. Which of the following would be one of the first signs?
a) Tachycardia
b) Hypertension
c) Hypothermia
d) Disseminated intravascular coagulation (DIC)

Correct answer: a

Copyright © 2017, Elsevier Inc. All Rights Reserved.

Answer Key for Blood Therapy 19

Rationale: An elevation in temperature or heart rate is one of the first signs that a person is
having an adverse reaction to a transfusion. Some patients also experience marked hypotension if
a severe reaction occurs. DIC is a later sign of a hemolytic transfusion reaction.

20. How long should the nurse stay with the patient after initiating a blood transfusion?
a) Until the transfusion is completed
b) 5 to 10 minutes
c) 15 minutes
d) 1 hour

Correct answer: c
Rationale: Most transfusion reactions occur within the first 15 minutes.

21. The nurse obtains the blood from the blood bank and is called away to see another patient.
Twenty minutes later, the nurse realizes that she will be unable to initiate the transfusion at this
time. What is the nurse’s best action?
a) Put the blood in the facility’s refrigerator.
b) Have the NAP initiate the transfusion under the nurse’s verbal direction.
c) Return the blood to the blood bank.
d) Discard the blood appropriately, and retrieve another one when able to administer it.

Correct answer: c
Rationale: If you cannot initiate the blood transfusion within 30 minutes from the time of
release from the blood bank, immediately return the blood to the blood bank and retrieve it when
you can administer it.

Copyright © 2017, Elsevier Inc. All Rights Reserved.

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 The profits are increased by selling the fish direct to consumers.
Fish-growing associations have been formed for this special purpose
all over the empire.
As these ponds are scattered all over the country it is possible to
have everywhere fish just out of the water; and, as I have said
before, the poorest variety of fish just caught has a finer Flavor than
the best variety that has been kept a few days by any method
whatever. I have lived in Germany three years and do not remember
ever to have had on my plate insipid fish, such as we are doomed
three times out of four to eat in our own country, chiefly because the
fish are frozen.
Dr. Wiley insists in his "Foods and Their Adulteration" (1911) that
"the consumer is entitled to know whether in any given case the fish
he purchases is a fresh or a cold storage article. At the present time,
in so far as I know, there are no national, state or municipal laws
whereby this fact can be ascertained. Without raising the question of
comparative value or palatability there is no doubt but what the
consumer is entitled to know the character of the fish he purchases."
Big Frauds in Fish: Under this head the "National Food Magazine"
of Chicago has published some remarks by G. J. L. Janes, which
vividly depict the outrages perpetrated in the United States by cold-
storage men.
"The legal regulations governing the sale of fish are so lax that
we have decided to stop handling fresh fish altogether rather than
suffer the unjust competition and be a party to so many deceptions
on the public. A dealer can take any kind of frozen fish, thaw it out,
and mark it strictly fresh-caught fish, and if he so desire, sell it as
such. This is being done all along State Street in Chicago to-day. It is
not only a fraud and cheat on the public, but it is dangerous. Fresh-
caught halibut costs 12 cents a pound wholesale. There is 20 per
cent. waste in it, because of the fins, skin, etc., and hence we have
to add 20 per cent. to the cost in order to break even on it.
Nevertheless certain stores are advertising strictly fresh-caught
halibut at 10-1/2 cents a pound retail. Of course this is frozen halibut
they are selling. That can be bought at 8 cents a pound wholesale.
The same is true of other fishes, especially white fish. That costs 22
cents a pound when fresh. Certain stores advertise "fancy white-fish
winter caught" at 10 cents retail. There is no mention of its being
frozen or cold storage fish, and so the public is deceived. It is
dangerous economy to buy cheap fish. No other food deteriorates so
rapidly after it comes from the water. Especially is this true of white
fish, which spoils quickest of all. Freezing breaks up the tissues, and
when it once is thawed it decomposes with enormous rapidity."
As long as the American public patiently tolerates such
impositions on purse and stomach it seems hardly worth while to
discuss the more subtle gastronomic problems, such as the question
put by Dr. Wiley: "Whether or not the flavor and character of the
flesh are impaired by the suffocation process subsequent to the
capture of the fish." Undoubtedly fish is best when killed the instant
it leaves the water, and then at once eviscerated and cleaned.
When we have become sufficiently civilized to insist on such
measures being taken, attention will be paid to the suggestions of
the Danish fisheries agent, Captain A. Solling, communicated to the
"Daily Consular and Trade Reports" by Consul-General Wallace C.
Bond, of Copenhagen. Captain Solling recommends that the fish, at
least the better kinds, be cut while yet alive, promptly cleaned, and
then wrapped in specially prepared paper which would prevent its
coming in direct contact with the chopped ice. The objection may be
raised, he admits, that this way of treating fish is too particular and
takes too long; but the increased work and the increased expense
will, he feels sure, soon be offset by the higher price secured on
account of the better preservation of the fish; and "the intelligent
fishmonger will soon discover the advantage of handling fish, which
if not sold to-day, may be sold in 3, 4 or 8 days and still be equally
good and fresh."
Progress along this line of gastronomic civilization will be a boon
to the American farmer. There are tens of thousands of lakelets and
ponds in our country, most of which might be used for fish culture.
They will be so used by farmers as soon as we have learned the
lesson the German ponds teach, and stopped buying the flavorless
frozen stuff sold in our fish markets.
In Switzerland there has been formed a Fish-Growers' Association
for the enlightenment of the land owners. Its motto is: "Every
Farmer a Fish Pond Owner." Attention is called to the demonstrated
fact that an acre of fish pond is more profitable than the same area
devoted to the ordinary farm crops.

GAME AND GEESE.

The same care that the Germans show in the growing and
transportation of fish is also manifested in their treatment of game.
During the automobile tour across Germany to which reference
has been made, we purposely stopped, as a rule, at the smaller
towns and taverns; but everywhere, without advance notice, we had
excellent food. I had previously come to the conclusion that the
average German restaurant serves nearly if not quite as good meals
as the average French restaurant, at least in the provinces.
It was game season, and everywhere we were able to get
partridges—plump young birds, juicy, and cooked scientifically, at
about one-third American prices.
Hares and rabbits are a German specialty, and Hasenrücken is a
very different thing from the undrawn rabbit abomination sold in
American markets. The Californian cottontail is the nearest approach
we have to the Teutonic hare. I shot dozens of them in Los Angeles
County one winter and found them as tender and almost as well
flavored as young chicken.
Venison is seldom to be had in our markets and usually only at
fancy prices. In German restaurants it is as cheap as beef;
sometimes cheaper. The back—Rehrücken—costs a trifle more, and
is better than the rest of the meat, which is usually served roasted
or as a ragout; but all is good. It seems to be a specialty of the
Rhine boats.
Other game also is abundant and cheap, for the simple reason
that the greed for sport is regulated by severe laws which are strictly
enforced. We, too, now have game laws in most of our States, but
they are seldom enforced effectively and most of them, moreover,
were made on the principle of locking the stable door after the horse
has been stolen.
Africa is at present the scene of ruthless slaughter of game, big
and little, but at its worst it is not often so reckless, extravagant, and
wasteful as the hideous carnage of which Americans have been
guilty. Time was when wild pigeons blackened the sky and were slain
by the hundreds with poles. Wild turkeys inhabited every thicket and
could be bought for twenty cents apiece—they are twice as much a
pound now, though seldom on sale at any price. Ruffled grouse were
so plentiful that a bounty was offered for their extermination, their
abundance being a menace to the crops. To-day you pay $5 for a
brace of these birds. Deer, until lately, were killed for their haunches,
the rest being left for beasts of prey; while millions of buffaloes were
slaughtered for their tongues and hides—often for the tongues
alone.
The Audubon Society, aided by generous donors and, to some
extent, by the Government, has done royal service to protect game
and song birds. The intelligent sporting clubs are lending useful aid,
while the Yellowstone Park has been set aside as a great game
preserve. Unfortunately, although the animals are safe from guns
while they remain in the Park, thousands are slaughtered in winter
when hunger drives them outside its limits, while many thousands
more perish because no provision is made for feeding these poor
wards of the Government.
A pathetic picture is printed in Dillon Wallace's splendid book,
"Saddle and Camp in the Rockies." It tells a sad story. One settler
told him there had been times when he could walk half a mile on the
bodies of dead elk. Instead of helping its wards, the Federal
Government actually gave permits to sheepmen which would have
devastated the last refuge of the elks. The settlers saved the
situation by holding an indignation meeting. "The sheepmen saw the
point—and the rope—and discreetly departed."
In Germany the game animals are cared for in winter. While
visiting Mark Twain's daughter and her husband, the eminent
pianist-composer, Ossip Gabrilowitsch, in the Bavarian Highlands, in
the summer of 1912, we met at their house a young tenor who was
also a mighty hunter before the Lord. He gave us an account of the
game laws and the general arrangements for preservation and
multiplication, which convinced us that if we are to retrieve the
errors and crimes of our predecessors, East and West, we must
follow the example of Germany.
Pointing to the meadows round about, he explained that the hay
made on these is preserved and fed to the deer in winter. Often one
may see as many as a hundred at a time assembling for their daily
meal, and people come all the way from Munich to see them at it.
As it had been found that too much hay or other dry food was
not good for the deer, the owners of private game preserves, of
which there are many, have taken to planting beets, turnips or
potatoes, which remain in the ground till the animals dig them out
from under the snow and soil.
A suggestive detail regarding the protection of birds is that
thickets, bristling with thorns, are specially provided to help them
during nesting time and when pursued by birds or beasts of prey.
The clearing away of thickets in America has done almost as much
as actual slaughter in exterminating birds. Lovers of song birds as
well as epicures who like game for a change would unite in blessing
our railway companies if they followed the German example of
planting shrubs as homes for birds all along the railroad
embankments.
While the Germans are fond of partridges and other game birds,
their favorite food, so far as the feathered tribes are concerned, is
the domesticated goose. In the markets, especially of the northern
cities, more geese are exposed for sale than all other kinds of
poultry combined, and in restaurants Gänsebraten is seldom absent
from the menu. The French rather look down on roast goose, but
that is because their roast goose is not so juicy and tender as the
Prussian, whether owing to a difference in variety or rearing I cannot
tell.
The Germans are most painstaking in the growing and the proper
feeding of this bird. They know that corn fodder yields the largest
amount of fat—and goose fat is much in demand—while the finest
Flavor is secured by feeding barley malt.
The best goose, like the best beef, is grown where there is
abundant pasturage. There is less of this in the Empire than there
used to be, hence large numbers of geese are imported. From six to
seven millions of them are annually brought across the border,
mostly from Russia. Every day, a special "goose train," consisting of
from fifteen to forty cars crosses the Russian frontier bound for
Berlin or Strassburg.
 Deer in German Forest

Strassburg is one of the many cities that were made famous by a

special food. Goose liver was already relished as a great delicacy by
the ancient Romans; Horace refers in one of his poems to the joys of
eating the liver of the white goose fattened with juicy figs. In
Strassburg, unfortunately, the geese are not fattened with figs, but
are locked up in cages and stuffed for a number of days with shelled
corn or noodles till their overworked livers become abnormally
enlarged, after which they are made into what is known the world
over as pâté de foie gras. This mixture of liver, meat and truffles is
now prepared on a large scale also in Toulouse and other French
places, but the headquarters for it is Alsace, where it is made in
many places, though it is said that there is a growing opposition to it
on account of the cruelty inseparable from the stuffing process. It's a
great pity that such cruelty should be necessary, for not a few
epicures feel like the Rev. Sydney Smith, who exclaimed: "My idea of
heaven is eating foies gras to the sound of trumpets."

IN A BERLIN MARKET.

That the goose is the food of the day and every day is made
manifest in the markets of Berlin, of which there are more than a
dozen. All the poultry stalls are filled with them, so much so that
other meat, even the ever-present veal, shrinks timidly into the
background.
Wherever one stops, the displays are most attractive. There are
unfrozen, fresh-killed meats of all kinds, tempting even the sightseer
who has no intention of buying. Autumn flowers, and large boxes of
deep red Preisselbeeren—a berry very similar to the mountain
cranberry found on Maine's highest peaks, and growing everywhere
in Germany (it ought to be acclimated in our fields)—give rich
autumnal hues to many of the market stalls, while the fragrance of
Gravenstein apples fills the air near the fruit stalls.
As in Paris, the sea fish are fresh-caught, with ice about them,
but never frozen, while fresh-water fish are carried to the buyer's
house in a tank and selected alive. The German krebs, or crawfish, is
almost as much in evidence as the French écrevisses, and like these,
it is kept in tanks of cold, running water, except for a few boxfuls,
the probable supply of the day, which are sorted out by sizes for
convenience. "Solo-krebs" is one of the items on a Berlin menu, and
means one huge fellow, almost as big as a small lobster.
This Berlin market, unlike the Halles of Paris, does not encroach
on and beautify the surrounding streets. It is orderly and law-
abiding, and fills up its allotted space of two covered squares to the
limit, but with no overflow. However, the shops nearby are generally
for foods, with appetizing windows of sausages, smoked meats and
fish, or cheeses.
An oddity of this market is that the upper floor space is divided
about equally between fruits and household furnishings. There is an
exhaustless supply of step-ladders, and besides these, every need of
the kitchen is provided for.
Meat prices, which soar in Berlin, are much lower in the big
markets than elsewhere.
Any one coming directly from the United States, where the veal is
seldom so good as the lamb or the beef is sure to wonder at the
abundance of calves in German markets. After sampling the veal a
few times, one ceases to wonder why the Germans are so addicted
to it, and the Austrians no less so. The French know how to cook
veal, and a good cutlet à la Milanaise is not to be despised, but there
is nothing in its way as good as the Wiener Schnitzel or the German
Kalbsbraten.
The excellence of German veal is due largely to the strict
exclusion from the markets by the meat inspectors of all animals
that are too young or too old, the Flavor as well as the tenderness of
the meat being largely dependent on the right age for slaughtering
the calf. The calves are, moreover, milkfed and not brought up on
"hay-tea."

VIENNA BREAD AND HUNGARIAN FLOUR.

 While Parisian bread is as good as bread can be, it cannot be
said that French bread, the country through, is so uniformly
excellent as is German bread, throughout the two Empires. Not only
in Vienna, Berlin, Munich, Dresden, Hamburg, Stuttgart, and the
other large cities is it almost invariably crisp and tasty, but it is so in
the smaller towns and even the villages.
Ellwanger does not exaggerate when he says in regard to
Germany that "from her inviting Bäckereis and Conditoreis floats an
ambrosial fragrance that may not be equaled by the pâtisseries of
Paris, the variety of her products being as great as their cheapness
and wholesomeness. One is born a poet, saith the adage; it is
equally true that the German is a born baker who has no superior in
his sphere."
The Parisians, indeed, learned the secret of making perfect bread
from the Austrians.
Bread was baked by Egyptians and Hebrews two thousand years
before Christ; also by the Greeks, from whom the Italians learned
the art of making it. There are records of Roman bakers who
became so wealthy and famous that they were invested with the
dignity of Senators, but there are reasons for believing that if any
bakers of our time endeavored to sell the sour stuff these Romans
made, they would be mobbed.
Eugen Baron Vaerst relates that a jury of French, English, and
Italian epicures decided that the best pastry was made in
Switzerland (Schweizerbäckerei has been famous for more than a
century) and the best bread in Vienna. The Austrians may have got
some hints from the Venetians, who made good bread and excellent
biscotti. In consequence of that jury's decision, an enterprising baker
set up a shop on the Boulevard Bonne Nouvelle, and "the Parisians,
proud to have all that was best in different countries taken to them
for their verdict and approval, decided that this was the best bonne
nouvelle that had ever been brought to them."
 This baker soon became wealthy and so did others who followed
his example. To this day pain viennois is in the best repute in Paris,
and so is Viennese pastry.
Most juries of epicures would agree to-day that not only is
Viennese bread perfect but that, next to Paris, the Austrian capital
has the best restaurants, and the most savory domestic cooking in
the world. Many of the foods served have local Flavors, not the least
agreeable of which are those betraying the neighborhood of
Hungary—the Gulyas, the Paprikahuhn, and other dishes reddened
and made piquant with paprika, which must not be confounded with
the much sharper variety of red pepper, cayenne, so dear to Spanish
peoples of the old world and the new.
A specialty of the Austrian and South-German cuisine, the neglect
of which elsewhere is incomprehensible, is the Mehlspeise, which
ought to be adopted in England and America as an occasional
substitute for puddings and pies. There is an endless variety of these
Mehlspeisen, under the species Nudeln, Spatzen, Kipferl, Kuchen,
Strudel, Nockerl, Flockerl, Knödel, Schmarren. Really, the
Kaiserschmarren and the Apfelstrudel ought to be adopted as
national American dishes by special act of Congress.
Flavorsome Hungarian flour (Mehl) is used in making these
dishes (Speisen) and that is one of the reasons why they are so
good. The Hungarian brand of flour is the best in the world,
especially the highest grade, known as Auszugmehl. It has an amber
tint known among bakers as the gelbliche Stich. On account of its
agreeable Flavor, Hungarian flour is sent in large quantities to
Germany, and some goes as far as Paris. Because of the freight
expenses it is not usually sent north of Berlin. In that city the best
bread is made of it, including the favorite Knüppel and the
Milchbrode. Farther north, a mixture of German and American flour
is used.
A few American grocers import Hungarian flour. The test of the
best European product is that when the hand is laid on it, it flies up
between the fingers. American flour packs. Mrs. Arpad Gerster
(whose husband is a brother of the famous Hungarian prima donna,
Etelka Gerster) gives me the very important information that our
flour can be made almost equal to the foreign by drying it on a
platter on top of the stove. Bread, cakes, noodles, etc., made with
flour thus dried have the much-coveted European lightness.
The Germans know as well as the French that the crust is the
sweetest and most digestible part of bread and that its Flavor
depends on there being a maximum of crust with a minimum of
crumb, quite as much as it does on the grade of flour used, and the
method of making the dough and baking it. To ensure a maximum of
crust, white bread is usually baked in the size of rolls, as Semmel,
and in a great variety of other shapes, every region having its
specialty.
While it is true that, as a German writer remarks, the eating of
white bread is a mark of prosperity in his country, it must not be
inferred that it is only the poorer classes who buy the cheaper
Schwarzbrod, made of rye. On account of its agreeable flavor this
"black-bread" appeals particularly to epicures, and the darkest
variety of it, Pumpernickel, is called for by gourmets the world over
as the best thing to eat with cheeses of the Limburger type. It is
also used as an ingredient in various Mehlspeisen and crêmes. It is
made of flour from which the bran has not been bolted.
Cereal perfumery is not a thing you can buy at an apothecary's.
You get it by munching a piece of rye bread with fresh butter on it
and consciously breathing out through the nose.
In France rye bread is almost unknown. In England attempts
were made a few years ago to popularize it. Nature and other
periodicals took up the matter, which had been brought to the fore
during a political campaign where some of the speakers deplored the
lot of the German laboring man for being obliged to eat rye bread.
By way of reply, attention was called to the fact that the Kaiser
himself always has rye bread on his table, and that in American
cities, as in those of Germany, there is much demand for such bread
in the wealthy quarters. Apparently the attempt to enrich the British
menu with a cheap new delicacy failed, for trade reports of 1912
intimated that while there is at all times a demand for corn and oats
on the Liverpool market, rye does not find sale there.
There are many other German bread and cake specialties that
deserve to be introduced in other countries. Two of them are already
known to epicures of many countries: the Lebkuchen, or honeycake,
which made Nuremburg famous, and the lye-soaked, twisted, crisp
Pretzel. This has a little salt strewn on the crust and the same is true
of other kinds of small breads. Particularly good is the Mohnbrot,
which is peppered with poppy seeds. Try it. Poppy seed is as good to
eat as any nut that grows.
In these things the Germans show a good deal of imagination;
but as for the anise-seeds so often mingled with the rye bread, I
wish they would leave them to the imagination. The general use of
them has probably done more than anything else to prevent the
acceptance of German rye bread in foreign countries.

GERMAN MENUS ON SEA AND LAND.

The Germans claim that the custom of providing a written or

printed menu, or Speisenkarte, originated in their country.
At a meeting of the Reichstag in Regensburg, in 1541, Count
Hugo of Montfort noticed one day at a banquet that the host, Duke
Heinrich von Braunschweig, had before him a Zettel, or slip of paper,
which he glanced at now and then. Being questioned, the Duke
replied that it was a list of the dishes that were to be served, made
for him by the chef so that he might save his appetite for those
which he liked best.
Whether true or not, the story gives the raison d'être for a menu
at every table-d'hôte meal. It is related by Friedrich Baumann in his
Meisterwerk der Speisen, a monumental work in two volumes, of
over two thousand pages, to which brief reference has already been
made. Baumann has been called the German Carême (who was "the
Luther of the French cuisine"). To him cooking was not mere
handwork; it was an art and a science; and in his work he not only
enumerates and briefly describes the foods of all countries (for
example, of fishes, and dishes made thereof, there are about
twenty-five hundred!), but treats of everything pertaining to the
growing, cooking, and serving of victuals with true German
thoroughness and with hundreds of those footnotes which are
accepted in that country as the best evidence of scholarship.
Of all the German cities none is visited by more American and
English tourists than Munich; and few of these fail to go and see the
Court Brewery, even though they may not wish to try the beer—the
best in the world. You may eat at the Hofbräuhaus without drinking
anything, though you will be stared at as a freak. There are several
large dining-rooms and the bill of fare is large, varied, and
thoroughly German. Look at the soups, for instance: bouillon with
egg, bread soup, noodle soup with or without a large chunk of
boiled chicken, which adds sixteen cents to the price, liver-noodle
soup, and brain soup. All are nutritious and tasty and cost only four
or five cents a big plate. The fishes offered on this particular day in
September are carp, pike, sand-eel from the Danube, and perch-
pike. These cost from about 27 to 32 cents a generous portion.
Ochsenfleisch—boiled beef—is always in great demand and is usually
juicy and well-flavored. Without vegetables it costs only 12 cents a
plate. Five different cuts of veal open the list of roasts, and the same
price is charged for them—17 cents—though in other restaurants the
kidney piece often costs a few cents more. Pork is two cents and a
half higher, while chicken, goose, and pigeon may rise to the dizzy
heights of 32 cents a plate.
Among the day's ready dishes—Fertige Speisen—we note haunch
of venison at 35 cents and leg of venison for five cents less. Half a
partridge is listed at 24 cents, and the same charge is made for a
quarter of a wild duck. There is of course a Sauerbraten—a sort of
bœuf à la mode with a palatable sour sauce—and you may choose
bœuf braisé, or Greek steak, or various mutton dishes, smoked
meats, and so on, the prices for these being about 22 to 24 cents,
including a vegetable: cabbage, potatoes, beans, or rice, noodles,
dumplings (Bavarian liver-dumplings—Leberknödel—are fine!) or
macaroni with minced ham, which ought to be on every table in
every country at least two or three times a week.
The roasts and fries to order include, of course, the Wiener
Schnitzel (savory when you have German or Austrian veal), the
Paprikaschnitzel and various other cuts from the calf or the ox.
Kompotts are in Germany served with roasts as regularly as salads
are in France; they are stewed fruits—apples, pears, apricots,
cherries, and berries among which the Preisselbeere is most Teutonic
and most delicious.
The Mehlspeisen on this particular menu are fewer in number
and less racy of the soil than those you would find on a Viennese bill
of fare. Besides the international omelette and the Italian macaroni
there is only the German pancake and the Windnudel. Among the
vegetables and salads are listed, rather out of place, the Spätzl, a
variety of the noodles which are the German version of the Italian
macaroni and other pastes, and which only a German knows how to
cook to perfection. A glance at the twenty-two varieties of cold
meats and appetizers and the dozen varieties of cheese brings to
mind the international aspect of German gastronomy.
In the more expensive restaurants of Munich and other German
cities the French influence is more obvious. I chose the menu of the
Hofbräuhaus because of its thoroughly bourgeois and German
aspect.
The largest restaurants in the world are in Berlin; one of them
seats four thousand people. In the bourgeois places the food is
usually less savory than in similar establishments in South Germany,
but there is a larger proportion of the high and highest class resorts,
with viands and prices almost, if not quite, on a level with those of
Paris and London, which it is the ambition and intention of the
Berliners ultimately to surpass in these respects as well as in the
splendors of their hotels.
 Breakfast.

Fruit
Oranges, Bananas, Grape Fruit, Grapes
Preserves
Honey, Strawberry Marmalade, Jams, Quince Jelly
Sweet Pickel Peaches, Scotch Marmalade
Coffee, Tea, etc.
Coffee, Coffeeïneless Coffee H. A. G., Cocoa, Chocolate
Ceylon Tea, Mixed Tea, Milk and Cream
Bread
Rolls, Milk and Butter Toast, Toast plain
Various Kinds of Cakes and Crackers
Cereals
Milk Rice, Oatmeal, Hominy, Force, Shredded Wheat, Grape Nuts
Eggs, Omelettes and Pancakes
Buckwheat, Hominy, Rice and Wheat Cakes,
Pancakes plain, with Apples or Cherries
Apricot or Currant Marmalade
Potato Pancakes,
Boiled Eggs, Poached Eggs, Baked Eggs
Fried Eggs plain, with Bacon or à la Tyrolienne
Scrambled Eggs plain, with Ham or à la Bavaroise
Omelette plain, aux fines Herbes or with Strawberries
Fish, Steaks, Chops etc.
Kippered Herrings, Haddock, Fish Croquettes, Sole, Salted Mackerels
Fillet Steak Westmoreland, Fillet of Veal Esterházy
Fillet Gulyàs with Mushrooms, German Beef Steak
Chicken Liver on the Spit with Piémontaise Rice
Calf's Liver with Apples and Onions, Fried Calf's Brains Sauce Rémoulade
Grill: Tenderloin Steak, Mutton Chops, Sirloinsteak, Lamb Kidneys,
English Ham, Frankfort Sausages
Potatoes
Boiled, Fried, Baked, Mashed Potatoes
Saratoga Chips, French Fried Potatoes, Lyonnaise Potatoes
 Cold Dishes
Westphalian Ham, Smoked Bologna Sausages, Smoked Tongue
Potted Fieldfares with Truffles, Roast Beef, Chicken
Relishes
Eel in Jelly, Oil Sardines, Anchovies, Fillet of Herring in diverser Sauce
Cheese
Camembert, Herb, Imperial, Holland Cheese
 Gabel-Frühstück—Luncheon
à la carte.
Vorspeisen
Salat de Boeuf Parisienne
Küken-Salat
Geräucherter Aal
Royans à la Bordelaise
Heringsfilet, Remouladensauce
Rollmops
Anchovis

Suppen
Hühner-Kraftbrühe in Tassen
Schottische Graupensuppe
Kartoffelsuppe mit Croutons

Fisch
Gerösteter Lachs, Anchovisbutter
Streifbarsch, Sauce Pluche

Eierspeisen
Omelett mit Schnittlauch
Spiegeleier Othello
Verlorene Eier Cardinal

Fleischspeisen und Geflügel

Küken in Curry und Reis
Kalbsleber mit Aepfeln und Zwiebeln Kartoffelmus
Zungenragout Financière, Fleurons
Entre-côtes à la Macédoine
Jungschweinskeule deutsche Art
Roastbeef au Jus

Bürgerliches Gericht
Klops à la Königsberg

Auf Bestellung (vom Grill 15 Min)

Hammelkoteletten, Beefsteak
Filetsteak, Rumpsteak

Gemüse und Kartoffeln

Brechspargel
Perlbohnen
Spaghetti italienische Art
Gekochter Reis
Französische und deutsche Bratkartoffeln
Kartoffelmus, Gebackene Kartoffeln

Salate
Kartoffelsalat, Achanaka-Salat

Kaltes Buffet
Lammrücken garniert
Galantine von Poularde, Sauce Cumberland
Chaud-froid von Reh mit Pilzen
Tournedos Jockey Art
Junge Ente in Aspik
Geräucherte Zunge
Gespicktes Kalbsfrikandeau, Roastbeef
Kaltes Geflügel
Geräucherter und gekochter Schinken

Kompott und Süßspeisen

Birnen
Blanc-manger mit Frchten
Schneebälle

Käse
Kräuter-, Schweizer-, Camembert-Käse

Frucht Kaffee

Hors d'Oeuvres
Salad de Boeuf Parisienne
Chicken Salad
 Smoked Eel
Royans à la Bordelaise
Fillet of Herrings, Sauce Remoulade
Rolled Pickled Herrings
Anchovies

Soups
Chicken Broth in Cup
Scotch Barley Soup
Potato Soup with Croutons

Fish
Broiled Salmon, Anchovy Butter
Striped Bass, Sauce Pluche

Eggs
Omelet with Chive
Fried Eggs Othello
Poached Eggs Cardinal

Entrées, Roasts and Poultry

Curried Chicken with Rice
Calf's-liver with Apples and Onions
Mashed Potatoes
Tongue Ragout Financière, Fleurons
Entre-côtes à la Macédoine
Leg of Pork, German Style
Roastbeef au Jus

Special Dish
Klops à la Koenigsberg

To Order (from the Grill 15 min.)

Mutton Chops, Beefsteak
Tenderloin Steak, Sirloin Steak

Vegetables and Potatoes

Cut Asparagus
String Beans
Spaghetti Italienne
Boiled Rice
French and German fried Potatoes
Mashed Potatoes, Baked Potatoes

Salads
Potato Salad, Salad Achanaka

Cold Cuts and Cold Dishes

Saddle of Lamb garnished
Galantine of Pullet, Sauce Cumberland
Chaud-froid of Venison, Mushrooms
Tournedos à la Jockey
Duckling in Aspic
Smoked Tongue
Larded Roast Veal, Roastbeef
Roast Chicken
Smoked and Boiled Ham

Compote and Desserts

Pears
Blanc-manger with Fruits
Cream Puffs

Cheese
Herb, Swiss, Camembert Cheese
Fruit Coffee
 Table-stewards and stateroom-
stewards will
take orders for dinner at any time
during
the day.

Carte du jour.
Hors d'Oeuvres:
Hors d'oeuvre Varié
Caprice Sticks

Soups:
Consommé Grimaldi
Cream Soup à la d'Orléans
Fieldfare Soup Old Style

Fish:
Salmon Cutlets à la Count d'Artois
Sole Meunière
Turbot, Butter, Parsley

Entrées:
Fillet of Beef Renaissance
Lamb Chops, Sauce Périgueux
Stuffed Artichoke Bottoms
Croutons of Goose Liver Moderne (cold)
Broiled Sweetbread, Green Peas
Entrecôtes Jardinière
Leg of Lamb, Larded, Brussels Sprouts

Grill: (15-30 min.):

Mixed Grill consisting of:
Fillet Mignon, Lamb Chops
Kidney, Sausage, Tomato
Tenderloin Steak, Entrecôte, Sirloin Steak
Lamb Chops, Mutton Chops

Ready Dishes:
 Prague Ham à la Fitz James

Poultry:
Cherbourg Poularde
Partridge

Vegetables:
Palm Marrow Bordelaise
Peas and Asparagus, Stew Corn
Boiled Rice
French and German fried Potatoes
Mashed Potatoes, Baked Potatoes

Compote:
Green Gages, Strawberries

Salads:
Lettuce Salad
Endive Salad

Sweets:
Strawberry Ice, Whipped Cream
Peaches à la Condé
Praline Ice Cream
Ice Napolitaine
Pastry
Cheese Fruit Coffee

A few Suggestions

I.
Hors d'oeuvre Varié
Cream Soup à la d'Orléans
Sole Meunière
Lamb Chops, Sauce Périgueux
Stuffed Artichoke Bottoms
Partridge
Compote Salad
 Strawberry Ice, Whipped Cream

II.
Fieldfare Soup Old Style
Salmon Cutlets à la Count d'Artois
Fillet of Beef Renaissance
Croutons of Goose Liver Moderne (cold)
Cherbourg Poularde
Compote Salad
Palm Marrow Bordelaise
Peaches à la Condé

III. (Supper)
Caprice Sticks
Consommé Grimaldi
Turbot, Butter, Parsley
Leg of Lamb, Larded, Brussels Sprouts
Praline Ice Cream
Pastry
 Another German ambition is to have the largest and most
comfortable floating hotels. The newest Hamburg and Bremen
steamers are indeed unsurpassed in any respect, and their cuisine is
particularly good. The trans-Atlantic steamers have the great
advantage of being able to buy in New York the best things
American markets offer, and in the German ports not only the
European delicatessen, but those which the sister boats bring from
Oriental countries. I once gained eight pounds in as many days
crossing the Big Pond on a German steamer; and can you wonder, in
view of the abundance of the choicest viands offered as antidotes to
the hunger-breeding sea air?
There are now on the largest steamers Ritz-Carlton restaurants
for wealthy epicures; but you need not go to these for good food, as
the sample menus for first-cabin breakfast, lunch, and dinner on the
Kaiserin Auguste Victoria, herewith reproduced, indicate. He must be
hard to please, indeed, who cannot find something on such menus
to tempt his appetite—unless he is sea-sick.

GERMAN, SWISS, AND DUTCH CHEESES.

German steamers and German restaurants nearly always offer a

variety of French, Dutch, Italian, English, and Swiss cheeses in
addition to those of their own country, among the best known of
which are the Handkäse, the Liptauer, the Harz, the Kräuter and the
Limburger, which, though it originated in Belgium, has come to be
looked upon as a specifically German variety.
Germany is not, like Switzerland, Holland, and parts of France, a
land of pastures green and studded with grazing cows. Pasturage
throughout the Empire is usually so scarce—the land being needed
for grain and other crops—that the cows, poor things, are kept in
stables all the year round. It is therefore, not surprising that
Germany is not among the great exporters of cheeses, most of the
many domestic varieties, some of which are excellent, being
consumed at home.
 Very different is the situation in Switzerland, where cheese-
making is one of the principal industries, the value of the exports
exceeding $12,000,000 a year, nearly one quarter of which, in 1911,
was sent to the United States. So good is the Flavor of
Schweizerkäse that even France, in that year, took $2,688,539 worth
of it, while Germany took $1,888,257 worth.
Nearly all the cheese which Switzerland exports is of the hard
Emmenthaler type, put up in the huge cakes familiar to us all. It is
practically the same as the French Gruyère. Not all Emmenthaler
comes from the Emmenthal, the valley where the pasturage is
particularly abundant and juicy.
The best flavored Swiss cheese is that which is made in summer,
when the cows roam the mountain sides, going up higher and higher
as the season advances and the snow melts, till they reach the
slopes where even at the end of August the soil is still moist and the
herbage two or three feet tall. This succulent food, consisting largely
of lovely Alpine flowers, they industriously condense into fragrant
cream, butter, and cheese.
When we speak of the Alps we mean snow mountains,
particularly those of Switzerland. The Swiss themselves, however,
when they refer to the Alps, mean the green pastures on the
mountain sides on which the cows gather sustenance and wealth for
them.
On one of these Alps, above Mürren, I once accosted a peasant
who gave me information which confirmed my belief that the much-
liked Flavor of Swiss cheese is due not alone to the succulent Alpine
forage, but also, in great part, to the way the best of it is made—
with all the cream left in the milk.
This peasant was himself a cheesemaker, and our conversation
took place within sight of his cowsheds. He was surprised when I
asked him if he ever used sour cream to make butter. He had never
dreamt of such a thing. Usually he churned it in the evening, using
the cream that had risen on the morning of the same day. At the
latest the churning was done the next morning before the cream
could possibly sour in that climate. A sour "starter," such as is nearly
always added to cream in America before it is churned, he had never
heard of; the very idea amazed him. And Swiss butter is nearly
always good, while American butter is usually bad.
Questioned in regard to cheese, he said they made two grades of
it, the Fettkäse, which contains all the cream, and the Magerkäse,
made of skim milk. For the latter kind, he said, he had no use,
because it was comparatively tasteless. It is made in considerable
quantities, however, for the poor, of milk from which the cream has
been taken for butter-making or for the hotel tables.
Cheese-making is much more of a fine art than most of us
imagine. The utmost skill and care must be used to exclude
undesirable flavors in the air due to uncleanly surroundings, since
cheese absorbs these as readily as butter does. The season of the
year and the feed must always be considered. Thus, in regard to the
highly prized English Stilton we read that the finest variety "is
principally made between March and September and solely from the
milk of cows fed on natural pasture"; and that "the use of artificial
food for the cows is at once detected in a change for the worse in
the character of the cheese"—that is, its flavor.
Upon good feeding depends the production of fat in milk, and
milk fat, alias cream, is a great source of Flavor. The best kinds of
most of the leading cheeses are made of whole milk—milk with none
of the cream taken out. Some kinds, like cottage cheese, are made
of skim milk yet how the addition of cream improves their Flavor!
Camembert, of course, is made of whole milk, and in the
manufacture of some kinds, including Stilton, extra cream is
sometimes added.
Much spurious stuff is palmed off on unwary buyers as whole
milk or cream cheese. The dealers who do this, think themselves
"smart," but in the end they harm their business. The excellent little
book on "Cheese and Cheese Making," by Long and Benson
(London: Chapman and Hall, 1896) begins with these instructive
words:
"Professor Henry, of the Wisconsin Agricultural College, recently
stated that the loss of the American cheese trade with great Britain
was owing to the fact that his countrymen did not make the best
article, and that in many cases imitation cheese was produced for
the sake of a possible temporary profit but to the ultimate loss of all
concerned. Whatever may be the immediate gain effected by the
addition of foreign fat to milk, or by the removal of a portion of the
cream it contains, the permanent value of the cheese industry to the
producer is maintained only by the manufacture of the best and of
its production in the largest possible quantity."
The italics are mine. They emphasize what is one of the most
regrettable aspects of the situation in America—the deplorable and
at the same time foolish disposition to make an immediate extra
profit by unloading on purchasers inferior cheeses and other foods in
the belief that the consumers are too ignorant or indifferent to know
or care what they get.
From personal experience I can relate a detail of New York
market history which vividly illustrates the folly of this attitude.
For several years I was able to buy the best Edam cheeses made
in Holland—full-cream and therefore full-flavored. One autumn, on
returning to the city, I tried in vain to get this same brand at the
places where it had been on sale. I sampled the substitutes but was
not satisfied with their Flavor. Having found out through a grocer the
name of the importer of that brand, I called on him and asked why
he no longer had it on his list. He had the effrontery to inform me
that it was because he had had so many complaints that that brand
did not keep well—that it "dried out." I told him that my own
experience had been just the reverse, and that, as a matter of
course, the more cream-fat there was in a cheese the more slowly it
would dry out. But he stuck to his story.
 In a confidential talk with a grocer I then ascertained what I had
suspected. Dealers in cheap Edams, made of skimmed milk, had
crowded out the maker of the creamy Edam who, of course, could
not make so low a price to the wholesale dealers as they did. "Why
not import several brands and charge according to their value and
Flavor?" I asked, adding that many persons surely would gladly pay
extra for the better grades. But that argument, too, was unavailing.
The "smart" dealers did not wish to offer several grades; they
wanted to charge the highest price for the lowest grade. And now
note the consequences.
In one large market which I often passed there was at that time
a large show case containing dozens of the familiar red "cannon
balls"; but they were no longer of the full-cream brand the lively
demand for which had won them the most prominent place in that
glass case. The new brand bore a label on which was printed "Made
of Skimmed Milk"; and this same brand seemed to be almost
exclusively on sale all over town.
There was nothing dishonest about this procedure. Dealers have
the right to sell any variety they choose, and this brand, being
clearly marked, did not pretend to be what it was not. It evidently
came from Holland, and it was as good a cheese as can be made of
skimmed milk.
The importers and dealers evidently believed that the consumers
were too ignorant or indifferent to care whether or not the cheese
they bought had the rich creamy Flavor. At first I feared they might
be right in this surmise, but ere long I found that I was by no means
the only person who had stopped buying Edam because the best
brand was no longer kept on sale in the American metropolis. The
number of red balls in that show case gradually diminished and
finally disappeared altogether.
The Dutch Government has given much attention to the question
of cream in cheese, and no wonder, for the annual production of
cheese in Holland amounts to at least 175,000,000 pounds, of which
two-thirds are exported. The Minister of Agriculture has authorized
the use of labels guaranteeing purity and quality. The Government
control stamp "can be used only on cheese made of unskimmed milk
and containing 45 per cent. of fats," writes Consul Frank W. Mahin
from Amsterdam. "It is the special intention to make the full-fat
product more profitable by marking it, which at the same time will
promote the manufacture of the cheese of superior qualities."
In another contribution on this subject to the "Consular and
Trade Reports" (April, 1911) Mr. Mahin provides information which
buyers of Edam or Gouda will do well to bear in mind:
"A meeting of the North Holland Cheese Control Station,
attended by a representative of the Government, was recently held
at Hoorn, at which it was decided to divide marked cheese into two
classes: (1) Cheese of Edam shape, with fatty component in the dry
material of at least 40 per cent., to be marked 40+, in a hexagon;
(2) full fat cheese, of different shapes, with a fatty substance in the
dry material of at least 45 per cent., to be marked Rijkscontrole
(Government control).
"It was stated at the meeting that the average proportion of fat
in the cheese made in 1910 by factories was 44.8 per cent. and by
farmers 47.5 per cent., being one per cent. higher than in 1909. The
quantity of marked cheese sold in 1910 was 45 per cent. greater
than in 1909, and the demand from dealers therefore has so much
increased that there is now a shortage."
Evidently, dealers are not everywhere as short-sighted as were
those of New York. However, in the autumn of 1912 I noticed,
among these, signs of almost human intelligence. Before the end of
1912 I saw in some stores Dutch cheeses labeled "Above 40%
butter-fat in total solids." By and by we may perhaps be permitted to
spend our money even for the kind made by the farmers and
containing 47.5 per cent. of cream fat.
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