NU 311 Clinical Nursing Skills Final Exam (NEW)
0 on phlebitis scale Correct Answer -No symptoms
-IV site appears healthy
1 on phlebitis scale Correct Answer -Erythema at access site
with or without pain
-One of the following signs is evident:
Slight pain near IV site or slight redness near IV site
2 on phlebitis scale Correct Answer -Pain at access site with
erythema and/or edema
-Two of the following signs are evident:
• Pain at IV site
• Erythema
• Swelling
3 on phlebitis scale Correct Answer -Pain at access site with
erythema and/or edema
-Streak formation
-Palpable venous cord
-All of the following signs are evident:
• Pain along the path of cannula
• Induration
4 on phlebitis scale Correct Answer -Pain at access site with
erythema and/or edema
-Streak formation
-Palpable venous cord >2.5 cm (1 inch) in length
-Purulent drainage
-All of the following signs are evident and extensive:
,• Pain along the path of cannula
• Erythema
• Induration
• Palpable venous cord
5 on phlebitis scale Correct Answer -All of the following
signs are evident and extensive:
• Pain along the path of cannula
• Erythema
• Induration
• Palpable venous cord
• Pyrexia
Acute hemolytic transfusion reaction Correct Answer -
Mechanism: Caused by ABO, Rh incompatibility; donor red
cells incompatible with recipient's plasma that can be potentially
fatal with as little as 10-15 mL of incompatible blood; usually
caused by administration of blood with wrong ABO blood group
as a result of misidentification or improper labeling
-Onset: Within minutes of transfusion initiation
-S&S: Fever with or without chills, tachycardia, hypotension,
lumbar/flank pain, hemoglobinemia, hemoglobinuria, dyspnea,
shock, oliguria or anuria, abnormal bleeding -Prevention: Proper
patient identification; proper labeling of blood sample;
meticulous verification of ABO/Rh compatibility between donor
and recipient before administration
-Nursing Intervention: Stop transfusion. Change administration
set and administer 0.9% sodium chloride at rate to maintain
patent IV access. Notify health care provider and blood bank.
Monitor vital signs at least every 15 min. Administer ordered
therapy to correct arterial blood pressure and coagulopathy.
,Insert Foley catheter. Monitor intake and output hourly. Assess
for shock. Dialysis may be required. Obtain blood and urine
samples and send to laboratory with unused part of unit of
blood. Document reaction according to agency policy.
Adverse Transfusion Reactions Correct Answer -Febrile,
nonhemolytic
-Acute hemolytic transfusion reaction
-Delayed hemolytic transfusion reaction (extravascular)
-Allergic reaction (mild-to-moderate)
-Allergic reaction (severe)
-Graft-versus-host disease
-Circulatory overload
-Infectious disease transmission
-Iron overload
Allergic reaction (mild-to-moderate) Correct Answer -
Mechanism: Thought to be caused by sensitivity reaction to
foreign plasma protein in transfused product
-Onset: Within minutes of transfusion initiation
-S&S: Local erythema; hives; and urticaria, itching, or pruritus
-Prevention: May administer antihistamines before transfusion if
prescribed
-Nursing Intervention: Stop transfusion. Change administration
set and administer 0.9% sodium chloride at rate to maintain
patent IV access. Notify health care provider and blood bank.
Administer antihistamines as ordered. Monitor and document
vital signs every 15 min. Transfusion may be restarted if fever,
dyspnea, and wheezing are not present.
, Allergic reaction (severe) Correct Answer -Mechanism:
Caused by recipient allergy to a donor antigen (usually IgA).
Agglutination of RBCs obstructing capillaries and blocking
blood flow, causing symptoms to all major organ systems
-Onset: Within minutes of transfusion initiation
-S&S: Coughing, nausea, vomiting, respiratory distress,
wheezing, hypotension, loss of consciousness, possible cardiac
arrest
-Prevention: Transfusion of saline-washed or leukocyte-depleted
RBCs
-Nursing Intervention: Stop transfusion. This is a life-
threatening reaction.
Change administration set and administer 0.9% sodium chloride
at rate to maintain patent IV access. Notify health care provider
and blood bank. Administer antihistamines, corticosteroids,
epinephrine, and antipyretics as ordered. Monitor and document
vital signs until stable. Initiate cardiopulmonary resuscitation if
necessary.
Avoid vein selection Correct Answer (1) Areas with pain on
palpation, compromised areas, sites distal to compromised areas
(e.g., open wounds, bruising, infection, infiltration, or
extravasation)
(2) Upper extremity on side of breast surgery with axillary node
dissection or lymphedema or after radiation, arteriovenous (AV)
fistulas/grafts; or affected extremity from cerebrovascular
accident (CVA)
(3) Site distal to previous venipuncture site, sclerosed or
hardened veins, previous infiltrations or extravasations, areas of
venous valves, or phlebitic vessels.
0 on phlebitis scale Correct Answer -No symptoms
-IV site appears healthy
1 on phlebitis scale Correct Answer -Erythema at access site
with or without pain
-One of the following signs is evident:
Slight pain near IV site or slight redness near IV site
2 on phlebitis scale Correct Answer -Pain at access site with
erythema and/or edema
-Two of the following signs are evident:
• Pain at IV site
• Erythema
• Swelling
3 on phlebitis scale Correct Answer -Pain at access site with
erythema and/or edema
-Streak formation
-Palpable venous cord
-All of the following signs are evident:
• Pain along the path of cannula
• Induration
4 on phlebitis scale Correct Answer -Pain at access site with
erythema and/or edema
-Streak formation
-Palpable venous cord >2.5 cm (1 inch) in length
-Purulent drainage
-All of the following signs are evident and extensive:
,• Pain along the path of cannula
• Erythema
• Induration
• Palpable venous cord
5 on phlebitis scale Correct Answer -All of the following
signs are evident and extensive:
• Pain along the path of cannula
• Erythema
• Induration
• Palpable venous cord
• Pyrexia
Acute hemolytic transfusion reaction Correct Answer -
Mechanism: Caused by ABO, Rh incompatibility; donor red
cells incompatible with recipient's plasma that can be potentially
fatal with as little as 10-15 mL of incompatible blood; usually
caused by administration of blood with wrong ABO blood group
as a result of misidentification or improper labeling
-Onset: Within minutes of transfusion initiation
-S&S: Fever with or without chills, tachycardia, hypotension,
lumbar/flank pain, hemoglobinemia, hemoglobinuria, dyspnea,
shock, oliguria or anuria, abnormal bleeding -Prevention: Proper
patient identification; proper labeling of blood sample;
meticulous verification of ABO/Rh compatibility between donor
and recipient before administration
-Nursing Intervention: Stop transfusion. Change administration
set and administer 0.9% sodium chloride at rate to maintain
patent IV access. Notify health care provider and blood bank.
Monitor vital signs at least every 15 min. Administer ordered
therapy to correct arterial blood pressure and coagulopathy.
,Insert Foley catheter. Monitor intake and output hourly. Assess
for shock. Dialysis may be required. Obtain blood and urine
samples and send to laboratory with unused part of unit of
blood. Document reaction according to agency policy.
Adverse Transfusion Reactions Correct Answer -Febrile,
nonhemolytic
-Acute hemolytic transfusion reaction
-Delayed hemolytic transfusion reaction (extravascular)
-Allergic reaction (mild-to-moderate)
-Allergic reaction (severe)
-Graft-versus-host disease
-Circulatory overload
-Infectious disease transmission
-Iron overload
Allergic reaction (mild-to-moderate) Correct Answer -
Mechanism: Thought to be caused by sensitivity reaction to
foreign plasma protein in transfused product
-Onset: Within minutes of transfusion initiation
-S&S: Local erythema; hives; and urticaria, itching, or pruritus
-Prevention: May administer antihistamines before transfusion if
prescribed
-Nursing Intervention: Stop transfusion. Change administration
set and administer 0.9% sodium chloride at rate to maintain
patent IV access. Notify health care provider and blood bank.
Administer antihistamines as ordered. Monitor and document
vital signs every 15 min. Transfusion may be restarted if fever,
dyspnea, and wheezing are not present.
, Allergic reaction (severe) Correct Answer -Mechanism:
Caused by recipient allergy to a donor antigen (usually IgA).
Agglutination of RBCs obstructing capillaries and blocking
blood flow, causing symptoms to all major organ systems
-Onset: Within minutes of transfusion initiation
-S&S: Coughing, nausea, vomiting, respiratory distress,
wheezing, hypotension, loss of consciousness, possible cardiac
arrest
-Prevention: Transfusion of saline-washed or leukocyte-depleted
RBCs
-Nursing Intervention: Stop transfusion. This is a life-
threatening reaction.
Change administration set and administer 0.9% sodium chloride
at rate to maintain patent IV access. Notify health care provider
and blood bank. Administer antihistamines, corticosteroids,
epinephrine, and antipyretics as ordered. Monitor and document
vital signs until stable. Initiate cardiopulmonary resuscitation if
necessary.
Avoid vein selection Correct Answer (1) Areas with pain on
palpation, compromised areas, sites distal to compromised areas
(e.g., open wounds, bruising, infection, infiltration, or
extravasation)
(2) Upper extremity on side of breast surgery with axillary node
dissection or lymphedema or after radiation, arteriovenous (AV)
fistulas/grafts; or affected extremity from cerebrovascular
accident (CVA)
(3) Site distal to previous venipuncture site, sclerosed or
hardened veins, previous infiltrations or extravasations, areas of
venous valves, or phlebitic vessels.
