N3280 – Health Assessment Across the Lifespan – Final Exam Questions and Answers:
Chapters 37–40 & Clinical Skills-Q&A
nursing intervention for blood transfusion allergic reaction stop the infusion immediately
and keep vein open with normal saline, notify provider, administer antihistamine parenterally
as necessary
S&S of febrile blood transfusion reaction fever and chills, headache, malase
nursing interventions for febrile blood transfusion reaction stop transfusion immediately
and keep vein open with normal saline, notify provider, treat symptoms
S&S of hemolytic blood transfusion reaction incompatibility of blood product, immediate
onset facial flushing, fever, chills, headache, low back pain, shock
nursing interventions for hemolytic reaction stop infusion immediately and keep vein open
with normal saline, notify provider, obtain blood samples, obtain first voided urine, treat shock
if present. Send unit, tubing, and filter to lab. Draw blood sample for testing and send urine
specimen to lab
S&S of blood transfusion circulatory overload reaction too much blood administered,
dyspnea, dry cough, pulmonary edema
nursing interventions for circulatory reaction slow or stop infusion, monitor vital signs,
notify provider, place in upright position with feet dependent
s&s of blood transfusion bacterial reaction bacteria present in blood, fever, hypertension,
flushed and dry skin, abdominal pain
,nursing interventions for bacterial reaction stop infusion immediately, obtain culture of
patient's blood and return blood bag to lab, notify provider, monitor vital signs, administer
antibiotics as ordered
When should vitals be gotten with blood transfusions? baseline vitals have to be within 30
minutes of starting, the second set of vitals must be gotten within 15 minutes after starting,
and every hour afterward
Blood typing and cross matching it must be determined that the blood on the donor is
compatible with that of the patient
Blood typing determining a person's blood type
Cross-matching determining compatibility between blood specimens
Antigen substance that causes the formation of antibodies
antibody protein substance developed in the body in response to the presence of an antigen
that has entered the body
Four main blood types A, B, AB, O
Which blood type is the universal donor? blood type O
Which blood type is the universal recipient? blood type AB
Rh factor an inherited protein found on the surface of red blood cells
,Rh negative must receive negative blood from the same type, lack the D antigen
rh positive can receive rh positive and negative blood of the same type
SA node located in right atrium, 60-100 BPM, how we get our normal HR
internodal tracts to AV node has internal HR
Purkinje fibers right and left ventricles, bottom of the heart, spread upward into the
ventricles
heart block prevents stimulus (electrical conduction) to get through
AV node controls the number of impulses that reach the ventricles, helps slow the impulse
as it comes through
normal sinus rhythm You will have a P wave for every QRS complex and then a T wave
Depolarization electrical current change inside the cell so it is positively charged and cardiac
contraction can occur
repolarization when the inside of the cell is returning to normal (negatively charged) and the
cardiac muscle is relaxing
P wave atrial depolarization (atrium are contracting)
, QRS complex ventricular depolarization (ventricles are contracting) AND atrial repolarization
T wave ventricular repolarization
ST if it is elevated, it could be STEMI
How do you count heart rate based on a rhythm strip? count the R waves (peak) and
multiply by 10. This is a rough estimate of the pt HR
Artifact ekg no discernable rhythm. can happen with movement, coughing, taking a shower,
etc.
Cardiac dysrhythmias impulse is too fast or slow and may or may not originate in the SA
node, a normal impulse that is interrupted in some way
ectopic beat an enhanced automaticity or excitability of atrial or ventricular tissue that
causes the impulse to initiate outside the normal conduction system
S&S of cardiac dysrhythmia chest pain, anxiety, diaphoresis, SOB, syncope, weakness,
dizziness, palpitations
S&S of decreased cardiac output decrease LOC, hypotension, tachycardia, tachypnea,
decrease urine output, cool, diaphoretic, pallor or cyanosis
Nursing care for cardiac dysrhythmias maximize cardiac output, monitor responses to
medications, teach self care
Chapters 37–40 & Clinical Skills-Q&A
nursing intervention for blood transfusion allergic reaction stop the infusion immediately
and keep vein open with normal saline, notify provider, administer antihistamine parenterally
as necessary
S&S of febrile blood transfusion reaction fever and chills, headache, malase
nursing interventions for febrile blood transfusion reaction stop transfusion immediately
and keep vein open with normal saline, notify provider, treat symptoms
S&S of hemolytic blood transfusion reaction incompatibility of blood product, immediate
onset facial flushing, fever, chills, headache, low back pain, shock
nursing interventions for hemolytic reaction stop infusion immediately and keep vein open
with normal saline, notify provider, obtain blood samples, obtain first voided urine, treat shock
if present. Send unit, tubing, and filter to lab. Draw blood sample for testing and send urine
specimen to lab
S&S of blood transfusion circulatory overload reaction too much blood administered,
dyspnea, dry cough, pulmonary edema
nursing interventions for circulatory reaction slow or stop infusion, monitor vital signs,
notify provider, place in upright position with feet dependent
s&s of blood transfusion bacterial reaction bacteria present in blood, fever, hypertension,
flushed and dry skin, abdominal pain
,nursing interventions for bacterial reaction stop infusion immediately, obtain culture of
patient's blood and return blood bag to lab, notify provider, monitor vital signs, administer
antibiotics as ordered
When should vitals be gotten with blood transfusions? baseline vitals have to be within 30
minutes of starting, the second set of vitals must be gotten within 15 minutes after starting,
and every hour afterward
Blood typing and cross matching it must be determined that the blood on the donor is
compatible with that of the patient
Blood typing determining a person's blood type
Cross-matching determining compatibility between blood specimens
Antigen substance that causes the formation of antibodies
antibody protein substance developed in the body in response to the presence of an antigen
that has entered the body
Four main blood types A, B, AB, O
Which blood type is the universal donor? blood type O
Which blood type is the universal recipient? blood type AB
Rh factor an inherited protein found on the surface of red blood cells
,Rh negative must receive negative blood from the same type, lack the D antigen
rh positive can receive rh positive and negative blood of the same type
SA node located in right atrium, 60-100 BPM, how we get our normal HR
internodal tracts to AV node has internal HR
Purkinje fibers right and left ventricles, bottom of the heart, spread upward into the
ventricles
heart block prevents stimulus (electrical conduction) to get through
AV node controls the number of impulses that reach the ventricles, helps slow the impulse
as it comes through
normal sinus rhythm You will have a P wave for every QRS complex and then a T wave
Depolarization electrical current change inside the cell so it is positively charged and cardiac
contraction can occur
repolarization when the inside of the cell is returning to normal (negatively charged) and the
cardiac muscle is relaxing
P wave atrial depolarization (atrium are contracting)
, QRS complex ventricular depolarization (ventricles are contracting) AND atrial repolarization
T wave ventricular repolarization
ST if it is elevated, it could be STEMI
How do you count heart rate based on a rhythm strip? count the R waves (peak) and
multiply by 10. This is a rough estimate of the pt HR
Artifact ekg no discernable rhythm. can happen with movement, coughing, taking a shower,
etc.
Cardiac dysrhythmias impulse is too fast or slow and may or may not originate in the SA
node, a normal impulse that is interrupted in some way
ectopic beat an enhanced automaticity or excitability of atrial or ventricular tissue that
causes the impulse to initiate outside the normal conduction system
S&S of cardiac dysrhythmia chest pain, anxiety, diaphoresis, SOB, syncope, weakness,
dizziness, palpitations
S&S of decreased cardiac output decrease LOC, hypotension, tachycardia, tachypnea,
decrease urine output, cool, diaphoretic, pallor or cyanosis
Nursing care for cardiac dysrhythmias maximize cardiac output, monitor responses to
medications, teach self care
