2

Question 1

If my blood pressure is 190/110, what is my pulse

pressure?

Answer 1

80 mm/hg

Systolic - diastolic (formula)

Question 2

What blood test must be done before a transfusion?

Answer 2

Type and cross match

Question 3

What does a type and cross match indicate?

Answer 3

Whether the client’s blood and donor blood are compatible.

Question 4

What should the nurse measure before starting a transfusion?

Answer 4

Vital signs

Question 5

With what solution should blood be transfused?

Answer 5

0.9 normal saline

Question 6

How many nurses are required to check the blood?

Answer 6

2 nurses

Question 7

What happens when blood is administered with Dextrose Is?

Answer 7

The cells clump together & don’t flow well.

Question 8

If a transfusion reaction occurs what should the nurse do first?

Answer 8

Stop the blood flow & start running the saline.

Question 9

How long can a unit of blood be on the unit before it must

be started?

Answer 9

Less than 1/2 hour

Question 10

What should the nurse do with the IV line if transfusion reaction is suspected?

Answer 10

Keep it open with saline

Question 11

If a transfusion reaction is suspected, what two samples

are collected and sent to the lab?

Answer 11

Urine & blood

Question 12

If a unit of blood is infused through a central line it must be

Answer 12

Warmed

Question 13

Which of the following are signs of transfusion reaction?

Answer 13

Bradycardia, Fever, Hives, Wheezing, increased Blood Pressure,
Low Back Pain: Low back pain, wheezing, fever, hives

Question 14

What are three types of transfusion reactions that can occur?

Answer 14

Hemolytic, febrile, allergic

Question 15

What would you do first if you suspected transfusion reaction?

Answer 15

Stop the blood and start the saline

Question 16

What are the signs and symptoms of a hemolytic transfusion reaction?

Answer 16

Shivering, HA, low back pain, increased

pulse & respirations, decreasing BP, oliguria, hematuria.

Question 17

What are the signs and symptoms of a febrile transfusion reaction?

Answer 17

Low back pain, shaking HA, increasing temperature, confusion, hemoptysis

Question 18

What are the signs of symptoms of an allergic reaction to a transfusion?

Answer 18

Hives- uticaria, wheezing, pruritus, joint pain, (arthralgia)

Question 19

Give three reasons for a blood transfusion

Answer 19

Restore blood
volume secondary to hemorrhage, maintain hemoglobin in
anemia, replace specific blood components.

Question 20

What does blood-typing mean?

Answer 20

Check for surface antigen on the red blood cell.

Question 21

When does typing and cross matching need to be done?

Answer 21

Whenever a client is to get a blood product. It is only good for
24 hours.

Question 22

What does blood cross matching mean?

Answer 22

Mixing a little of

the client’s blood with the donor blood and looking for agglutination.

Question 23

When are hemolytic transfusion reactions likely to occur?

Answer 23

In the first 10 to 15 minutes

Question 24

When is a febrile reaction likely to occur?

Answer 24

Within 30 minutes of beginning the transfusion.

Question 25

What test identifies Rh factor?

Answer 25

Coombs test detects antibodies to Rh

Question 26

What is the difference between whole blood and packed cells?

Answer 26

Packed cells don't have nearly as much plasma or volume as whole blood does

Question 27

What would you do if the client had an increasing temperature and was to get blood?

Answer 27

Call the MD because | blood is often held with an elevated temperature

Question 28

blood is often held with an elevated temperature | 130. How long should it take for one unit of blood to infuse?

Answer 28

From one hour to three hours

Question 29

What blood type is the universal recipient?

Answer 29

AB

Question 30

What blood type is the universal donor?

Answer 30

O

Question 31

What is the routine for vital sign measurement with a transfusion?

Answer 31

Once before administration 015 x2 after administration is begun 01 x1 after transfusion has stopped

Question 32

What IV solution is hung with a blood transfusion?

Answer 32

0.9 normal saline (No glucose)

Question 33

What gauge needle is used with a blood transfusion?

Answer 33

Large gauge, 18 gauge

Question 34

What other things are appropriate after a reaction?

Answer 34

Call MD, get a blood sample, get urine sample, monitor vitals, send blood to lab

Question 35

Can blood be given immediately after removal from refrigeration?

Answer 35

No, it has to be warmed first for only about 20 to 30 minutes.

Question 36

With what solution & when should a breast feeding mother cleanse the areola?

Answer 36

Plain water, before & after each feeding

Question 37

For a woman who doesn't have retracted nipples, is towel drying or air drying better?

Answer 37

Air drying of the nipples is best

Question 38

The goal is for the infant to breast feed for

Answer 38

20 minutes per side.

Question 39

How does the mother break the suction of the breast feeding infant?

Answer 39

She inserts her little finger into the side of the infant's mouth

Question 40

When should the breast feeding infant be burped?

Answer 40

After feeding from each breast

Question 41

Assuming no mastitis, on which side should the breastfeeding begin?

Answer 41

Begin nursing on the side that the baby | finished on the last feeding.

Question 42

How long can breast milk be refrigerated?

Answer 42

24 hours

Question 43

How long can breast milk be frozen?

Answer 43

6 months

Question 44

In what type of container should breast milk be stored?

Answer 44

Sealed plastic bags

Question 45

Can you microwave frozen breast milk in order to warm/thaw it?

Answer 45

Never

Question 46

Which two nutrients is breast milk lower in?

Answer 46

Fluoride and iron

Question 47

What should you tell a breast feeding mother about her milk supply when she goes home from the hospital?

Answer 47

Milk should come in postpartum day 3. Breastfeed every 2-3 hours to establish good milk supply.

Question 48

Can a woman on oral contraceptives breastfed?

Answer 48

Should not use OCP during the first 6 weeks after birth because the hormones may decrease milk supply. Estrogen is not recommended. Non-hormonal methods are recommended. Remember, breastfeeding is an unreliable contraceptive.

Question 49

What is another name for Burger's disease?

Answer 49

Thrombo angiitis obliterans

Question 50

Which extremities are affected by Burger's disease?

Answer 50

Lower extremities

Question 51

Which sex does it affect the most often? (Burger's disease)

Answer 51

Males

Question 52

The group with the highest incidence of Burger's disease is:

Answer 52

Smokers

Question 53

Upon walking the patient with Burger's experiences

Answer 53

Intermittent Claudication

Question 54

What is intermittent claudication?

Answer 54

Pain in calf upon walking

Question 55

A first degree burn is pale or red?

Answer 55

Red

Question 56

First degree burn has vesicles? T or F

Answer 56

False

Question 57

A second-degree burn is pale or red?

Answer 57

Red

Question 58

A second-degree burn is dull or shiny?

Answer 58

Shiny

Question 59

A second-degree burn has vesicles?

Answer 59

True

Question 60

A third-degree burn is white or red?

Answer 60

White

Question 61

A third-degree burn is wet or dry?

Answer 61

Dry

Question 62

A third degree burn is hard or soft?

Answer 62

Hard

Question 63

Of first, second and third degree burns which has less | pain? Why?

Answer 63

Third degree burns, nerve damage has occurred

Question 64

For what purpose do you use the rule of nines?

Answer 64

To estimate the percentage of body surface burned; is NOT used for children.

Question 65

What is the only IM given to a burn patient?

Answer 65

Tetanus toxoid- if they had a previous immunization; tetanus antitoxin- if they have never been immunized before (or immune globulin)

Question 66

In the emergent phase do you cover burns?

Answer 66

(in the field): | Yes, with anything clean and dry.

Question 67

Should you remove adhered clothing?

Answer 67

No

Question 68

Name the 3 phases of burn:

Answer 68

Shock, diuretic, recovery

Question 69

Fluid moves from the bloodstream to the interstitial:

Answer 69

in the SHOCK phase.

Question 70

The shock phase lasts for the

Answer 70

first 24 to 48 hours after a | burn.

Question 71

During shock phase of a burn is potassium increased or | decreased? Why?

Answer 71

Increased, because of all the cells damaged- | the K+ is released from damaged cells.

Question 72

What acid-base disorder is seen in the shock phase of a burn?

Answer 72

Metabolic Acidosis

Question 73

What is the #1 therapy in the shock phase?

Answer 73

Fluid replacement/resuscitation

Question 74

What is the simple formula for calculating fluid replacement needs in the first 24 hours?

Answer 74

3cc X Kg X% | burned per day

Question 75

What blood value will dictate IV flow rate?

Answer 75

The hematocrit

Question 76

How will you know the patient has entered the fluid mobilization or diuretic phase?

Answer 76

The urine output will Increase

Question 77

How long does the fluid mobilization or diuretic phase of a burn last?

Answer 77

2 to 5 days

Question 78

In the diuretic phase, K+ levels fall or rise?

Answer 78

Fall- remember diuresis always causes hypokalemia

Question 79

If the nurse accidentally runs the IVs at the shock phase rate during the diuretic phase the patient will experience?

Answer 79

Pulmonary edema

Question 80

The burn patient will be on hourly urine output and daily weight.

Answer 80

The burn patient will be on hourly urine output and daily weight.

Question 81

Sulfamyon cream is used for

Answer 81

Burns

Question 82

Silver nitrate cream

Answer 82

Stains the skin

Question 83

Pain medications should be administered

Answer 83

30 minutes before wound

Question 84

When using silver nitrate, the dressings must be kept

Answer 84

Wet

Question 85

What is Curlings ulcer? Why is it a problem in burn | patients? What drug prevents it?

Answer 85

It is a stress Gl ulcer, you get these with any severe physical stress. Tagamet, Zantac, Pepcid (any H2 receptor antagonist), Protonix Prilosec

Question 86

Abruptio Placenta usually occurs in (prima/multi) gravida over the age of

Answer 86

Multigravida, 35 (HTN, trauma, cocaine)

Question 87

How is the bleeding of Abruptio Placenta different from that in placenta previa?

Answer 87

usually pain; bleeding is more | voluminous in previa

Question 88

If you are the nurse starting the IV on the client with | Abruptio Placenta, what gauge needle should you use?

Answer 88

18 (in preparation to give blood if necessary)

Question 89

How often should you measure the vital signs, vaginal | bleeding, fetal heart rate during Abruptio Placenta?

Answer 89

Q5-15 minutes for bleeding and maternal VS, continuous fetal monitoring, deliver at earliest sign of fetal distress

Question 90

How is an infant delivered when Abruptio Placenta is present?

Answer 90

Usually C-section

Question 91

Is there a higher or lower incidence of fetal death with Abruptio Placenta compared to Placenta Previa?

Answer 91

Higher

Question 92

In what trimester does Abruptio Placenta most commonly occur?

Answer 92

Third

Question 93

At what age are accidental poisonings most common?

Answer 93

2 years old

Question 94

If a child swallows a potentially poisonous substance, what should be done first?

Answer 94

call medical help

Question 95

Should vomiting be induced after ingestion of gasoline?

Answer 95

No- not for gas or any other petroleum products

Question 96

When taking a child to the ER after accidental poisoning | has occurred what must accompany the child to the ER?

Answer 96

the suspected poison

Question 97

An elderly client is a (high/low) risk for accidental | poisoning? What about a school age child?:

Answer 97

high - due to poor eyesight, high

Question 98

What types of chemicals cause burns to oral mucosa when ingested?

Answer 98

Lye, caustic cleaners

Question 99

Children at highest risk for seizure activity after ingestion are those who have swallowed

Answer 99

drugs and Insecticides.

Question 100

Can impaired skin integrity ever be an appropriate nursing | diagnosis when poisoning has occurred?

Answer 100

Yes, when lye or caustic agents have been ingested

Question 101

What is the causative organism of acne?

Answer 101

Propionibacterium acnes

Question 102

What structures are involved in acne vulgaris?

Answer 102

The sebaceous glands

Question 103

Name 3 drugs given for acne?

Answer 103

Vitamin A, Antibiotics, Retinoids

Question 104

Dietary indiscretions and uncleanliness are causes of acne?

Answer 104

False