RNSG 2539 EXAM 1 (Perfusion, Clotting, Fluid
and Electrolytes) Questions With Complete
Solutions
allergic reaction to transfused blood
| | | |
hives, itching, anaphylaxis
| |
MI EKG changes
| |
1. peaked T waves (early)
| | | |
2. ST segment elevation (indicates transmural injury/acute infarct)
| | | | | | |
3. Q waves (indicates necrosis; late; specific)
| | | | | |
4. T wave inversion (sensitive but nor specific)
| | | | | | |
5. ST segment depression (indicates subendocardial injury)
| | | | | |
nursing interventions to allergic reaction to blood product
| | | | | | |
stop transfusion and keep vein open with normal saline
| | | | | | | |
notify primary care provider immediately
| | | |
administer antihistamine parenterally as necessary
| | | |
Febrile reaction to blood transfusion
| | | |
fever, chills, headache, malaise
| | |
nursing interventions to febrile reaction to blood product
| | | | | | |
stop transfusion immediately and keep vein open with normal saline
| | | | | | | | |
notify primary care provider
| | |
,treat symptoms
|
hemolytic transfusion: incompatibility of blood product
| | | | |
immediate onset of facial flushing, fever, chills, headache, low back pain, shock
| | | | | | | | | | |
nursing intervention for hemolytic transfusion incompatibility of a blood product
| | | | | | | | |
stop infusion immediately and keep vein open with normal saline
| | | | | | | | |
notify md |
obtain blood samples from the site
| | | | |
obtain first voided urine
| | |
treat shock if present
| | |
send unit, tubing, and filter to lab
| | | | | |
draw blood sample for geologic testing and send urine specimen to lab
| | | | | | | | | | |
circulatory overload: too much blood administered
| | | | |
dyspnea, dry cough, pulmonary edema
| | | |
nursing interventions for circulatory overload of blood product
| | | | | | |
slow or stop infusion
| | |
monitor VS |
notify primary care provider
| | |
place in upright position with feet dependent
| | | | | |
bacterial reaction of blood product
| | | |
,fever, hypertension, dry, flushed skin
| | | |
nursing interventions of a blood product
| | | | |
stop infusion immediately
| |
obtain culture of patients blood and return blood bad to lab
| | | | | | | | | |
notify primary care provider
| | |
administer antibiotics as ordered | | |
cross matching |
the process of determining compatibility between blood specimens
| | | | | | |
nurses should have another nurse check off what prior to administering a blood
| | | | | | | | | | | | |
product
blood type |
Rh factor
|
donation ID # | |
expiration date |
date/time issued |
baseline vital signs | |
prime blood tubing with what
| | | |
normal saline |
facility policy when administering blood products
| | | | |
frequency is normally 15 min first hour, every hour after 4 hours
| | | | | | | | | | |
what timeframe should you administer blood within
| | | | | |
30 min of receiving from bank = hung
| | | | | | |
4 hours = administered and complete
| | | | |
, d/c if longer than 4 hours
| | | | |
stop infusion if reaction occurs and follow the agency's transfusion reaction
| | | | | | | | | | |
standard
HIT also Heparin induced thrombocytopenia
| | | |
complication of heparin therapy | | |
decrease in platelet count after 5 to 10 days
| | | | | | | |
platelet count should be monitored in any patient beginning heparin
| | | | | | | | |
pathology of HIT | |
Heparin forms a complex w/ platelet factor 4 --> produces IgG antibodies which
| | | | | | | | | | | | |
destroy platelets |
The remnants activate remaining platelets, leading to thrombus formation
| | | | | | | |
increased consumption of platelets causes Thrombocytopenia
| | | | |
HIT clinical manifestations
| |
increase r/o thrombosis (venous, arterial, both)
| | | | |
VTE = DVT or PE
| | | |
thrombocytopenia is usually not significant enough to cause bleeding | | | | | | | |
HIT treatment
|
D/C heparin
|
initiate anticoagulation ARGATROBAN
| |
should receive anticoagulation for 3-6 months
| | | | |
and Electrolytes) Questions With Complete
Solutions
allergic reaction to transfused blood
| | | |
hives, itching, anaphylaxis
| |
MI EKG changes
| |
1. peaked T waves (early)
| | | |
2. ST segment elevation (indicates transmural injury/acute infarct)
| | | | | | |
3. Q waves (indicates necrosis; late; specific)
| | | | | |
4. T wave inversion (sensitive but nor specific)
| | | | | | |
5. ST segment depression (indicates subendocardial injury)
| | | | | |
nursing interventions to allergic reaction to blood product
| | | | | | |
stop transfusion and keep vein open with normal saline
| | | | | | | |
notify primary care provider immediately
| | | |
administer antihistamine parenterally as necessary
| | | |
Febrile reaction to blood transfusion
| | | |
fever, chills, headache, malaise
| | |
nursing interventions to febrile reaction to blood product
| | | | | | |
stop transfusion immediately and keep vein open with normal saline
| | | | | | | | |
notify primary care provider
| | |
,treat symptoms
|
hemolytic transfusion: incompatibility of blood product
| | | | |
immediate onset of facial flushing, fever, chills, headache, low back pain, shock
| | | | | | | | | | |
nursing intervention for hemolytic transfusion incompatibility of a blood product
| | | | | | | | |
stop infusion immediately and keep vein open with normal saline
| | | | | | | | |
notify md |
obtain blood samples from the site
| | | | |
obtain first voided urine
| | |
treat shock if present
| | |
send unit, tubing, and filter to lab
| | | | | |
draw blood sample for geologic testing and send urine specimen to lab
| | | | | | | | | | |
circulatory overload: too much blood administered
| | | | |
dyspnea, dry cough, pulmonary edema
| | | |
nursing interventions for circulatory overload of blood product
| | | | | | |
slow or stop infusion
| | |
monitor VS |
notify primary care provider
| | |
place in upright position with feet dependent
| | | | | |
bacterial reaction of blood product
| | | |
,fever, hypertension, dry, flushed skin
| | | |
nursing interventions of a blood product
| | | | |
stop infusion immediately
| |
obtain culture of patients blood and return blood bad to lab
| | | | | | | | | |
notify primary care provider
| | |
administer antibiotics as ordered | | |
cross matching |
the process of determining compatibility between blood specimens
| | | | | | |
nurses should have another nurse check off what prior to administering a blood
| | | | | | | | | | | | |
product
blood type |
Rh factor
|
donation ID # | |
expiration date |
date/time issued |
baseline vital signs | |
prime blood tubing with what
| | | |
normal saline |
facility policy when administering blood products
| | | | |
frequency is normally 15 min first hour, every hour after 4 hours
| | | | | | | | | | |
what timeframe should you administer blood within
| | | | | |
30 min of receiving from bank = hung
| | | | | | |
4 hours = administered and complete
| | | | |
, d/c if longer than 4 hours
| | | | |
stop infusion if reaction occurs and follow the agency's transfusion reaction
| | | | | | | | | | |
standard
HIT also Heparin induced thrombocytopenia
| | | |
complication of heparin therapy | | |
decrease in platelet count after 5 to 10 days
| | | | | | | |
platelet count should be monitored in any patient beginning heparin
| | | | | | | | |
pathology of HIT | |
Heparin forms a complex w/ platelet factor 4 --> produces IgG antibodies which
| | | | | | | | | | | | |
destroy platelets |
The remnants activate remaining platelets, leading to thrombus formation
| | | | | | | |
increased consumption of platelets causes Thrombocytopenia
| | | | |
HIT clinical manifestations
| |
increase r/o thrombosis (venous, arterial, both)
| | | | |
VTE = DVT or PE
| | | |
thrombocytopenia is usually not significant enough to cause bleeding | | | | | | | |
HIT treatment
|
D/C heparin
|
initiate anticoagulation ARGATROBAN
| |
should receive anticoagulation for 3-6 months
| | | | |
