Exam 2: NR226 / NR 226 (Latest
Update ) Fundamentals:
Patient Care | Comprehensive
Review Questions and Answers |
100% Correct | Grade A -
Chamberlain
Question:
What is the purpose of saving all blood, tubing, and labeling after a blood
transfusion reaction takes place?
Answer:
The purpose of saving the blood, tubing, and labeling is to evaluate if an error
occurred in the blood administration process.
Question:
Which findings can suggest an acute hemolytic reaction after starting a blood
transfusion? Select all that apply.
Answer:
Fever, blood in the urine, and hypotension are signs of an acute hemolytic
reaction.
,Question:
Which findings suggest delayed complications of a peripheral intravenous
(IV) catheter? Select all that apply.
Answer:
When an IV is in for a long time, there is always a risk of infection,
infiltration, bleeding, and pain.
Question:
A client with a low sodium level and a low serum osmolality level would be in
which state?
Answer:
The client is in a hypotonic state due to low serum osmolality and low sodium
levels. A hypotonic state refers to a decrease in electrolyte concentration in
the extracellular fluid. In a hypotonic state, the cells grow as water in the
extracellular fluid moves toward the higher sodium concentration inside the
cells.
An isotonic state occurs when the electrolyte concentration stays the same but
there is an overall bodily fluid loss. A hypertonic state also known as
hypernatremia, refers to an imbalance of water and sodium in the body
characterized by relatively increased levels of sodium. Generally, when water
is excreted from the body, electrolyte (e.g., sodium) concentrations in the
blood increase. A hypertonic state occurs when an individual excretes too
much water without also excreting electrolytes, leaving the fluid that
surrounds cells (i.e., extracellular fluid) with a high sodium concentration. A
high concentration of sodium outside a cell will draw water out of the cell,
towards the sodium. As water leaves the cell, the cell shrinks.
,Question:
Appropriate Fluids
Fred (pronouns: he/him/his) was admitted with a ruptured abdominal aortic
aneurysm. After surgery, his bleeding is now under control, but he has lost a
fair amount of blood. His blood pressure is 90/50, and his pulse rate is 130
bpm (beats per minute). His hemoglobin is 7.0 and his hematocrit is low.
Which fluid would be appropriate based on the vitals, labs, and
circumstances? Select all that apply.
Answer:
0.9% normal saline is isotonic and because his hemoglobin is low, PRBCs
would be most appropriate in this situation.
Question:
Evaluate Intravenous Site
Answer:
, Question:
Fred appears to be experiencing a febrile non-hemolytic reaction. Which of
the following nursing actions would you would perform? Select all that apply.
Answer:
The nurse should remain with the client, record signs and symptoms, and
monitor vital signs at 5-minute intervals. The blood administration tubing
should always be immediately removed for a new IV administration set to
prevent the blood in the tubing from being given to the client. The blood
container, tubing, labels, and records should always be saved and returned to
the blood bank for analysis. The report should go immediately to the
healthcare provider and emergency management team to ensure further
orders as needed, and vital signs should be done every 5 minutes. The nurse
should always be prepared for an emergency situation.
Question:
Assessment
Answer:
Frequently, the nurse assesses clients who will be starting or continuing
intravascular therapy for a number of reasons. Key factors when assessing
these clients include:
hydration status
reasons for therapy
potential risks
continued maintenance
Update ) Fundamentals:
Patient Care | Comprehensive
Review Questions and Answers |
100% Correct | Grade A -
Chamberlain
Question:
What is the purpose of saving all blood, tubing, and labeling after a blood
transfusion reaction takes place?
Answer:
The purpose of saving the blood, tubing, and labeling is to evaluate if an error
occurred in the blood administration process.
Question:
Which findings can suggest an acute hemolytic reaction after starting a blood
transfusion? Select all that apply.
Answer:
Fever, blood in the urine, and hypotension are signs of an acute hemolytic
reaction.
,Question:
Which findings suggest delayed complications of a peripheral intravenous
(IV) catheter? Select all that apply.
Answer:
When an IV is in for a long time, there is always a risk of infection,
infiltration, bleeding, and pain.
Question:
A client with a low sodium level and a low serum osmolality level would be in
which state?
Answer:
The client is in a hypotonic state due to low serum osmolality and low sodium
levels. A hypotonic state refers to a decrease in electrolyte concentration in
the extracellular fluid. In a hypotonic state, the cells grow as water in the
extracellular fluid moves toward the higher sodium concentration inside the
cells.
An isotonic state occurs when the electrolyte concentration stays the same but
there is an overall bodily fluid loss. A hypertonic state also known as
hypernatremia, refers to an imbalance of water and sodium in the body
characterized by relatively increased levels of sodium. Generally, when water
is excreted from the body, electrolyte (e.g., sodium) concentrations in the
blood increase. A hypertonic state occurs when an individual excretes too
much water without also excreting electrolytes, leaving the fluid that
surrounds cells (i.e., extracellular fluid) with a high sodium concentration. A
high concentration of sodium outside a cell will draw water out of the cell,
towards the sodium. As water leaves the cell, the cell shrinks.
,Question:
Appropriate Fluids
Fred (pronouns: he/him/his) was admitted with a ruptured abdominal aortic
aneurysm. After surgery, his bleeding is now under control, but he has lost a
fair amount of blood. His blood pressure is 90/50, and his pulse rate is 130
bpm (beats per minute). His hemoglobin is 7.0 and his hematocrit is low.
Which fluid would be appropriate based on the vitals, labs, and
circumstances? Select all that apply.
Answer:
0.9% normal saline is isotonic and because his hemoglobin is low, PRBCs
would be most appropriate in this situation.
Question:
Evaluate Intravenous Site
Answer:
, Question:
Fred appears to be experiencing a febrile non-hemolytic reaction. Which of
the following nursing actions would you would perform? Select all that apply.
Answer:
The nurse should remain with the client, record signs and symptoms, and
monitor vital signs at 5-minute intervals. The blood administration tubing
should always be immediately removed for a new IV administration set to
prevent the blood in the tubing from being given to the client. The blood
container, tubing, labels, and records should always be saved and returned to
the blood bank for analysis. The report should go immediately to the
healthcare provider and emergency management team to ensure further
orders as needed, and vital signs should be done every 5 minutes. The nurse
should always be prepared for an emergency situation.
Question:
Assessment
Answer:
Frequently, the nurse assesses clients who will be starting or continuing
intravascular therapy for a number of reasons. Key factors when assessing
these clients include:
hydration status
reasons for therapy
potential risks
continued maintenance
