Exam 1 chapter 20

Question 1

predisposing factors to DVT

Answer 1

previous DVT
smoking
contraceptive 
age
cardiovascular disorder
weight 
gender

Question 2

what is are the 3 stages of Virchow’s Tried

Answer 2

stasis of blood
vessel wall injury
altered coagulation

Question 3

Nursing assessment for DVT

Answer 3

edema-bilateral baseline limb girth
skin temperature-warm
pain
color
pyrexia
pulse

Question 4

therapeutic intervention for DVT

Answer 4

increase fluids
early mobilization
ROM
bed rest
planter and dorsiflexion 
ambulate
meals

Question 5

Elastic compression stockings (TED hose)

Answer 5

increase venous return
risk-low
mod/high with anticoagulants
apply correctly with band, wrinkles, size

Patient teaching: don’t roll down, don’t cut
off for an 1 per shift

Question 6

what is the antidote for warfarin (coumadin)

Answer 6

Vitamin K

Question 7

hgb

Answer 7

12-18

Question 8

HCT

Answer 8

38-54%

Question 9

RBC

Answer 9

4-6

Question 10

platelet count

Answer 10

150,000-400,000

Question 11

WBC

Answer 11

5-10

Question 12

if neutrophils increase and lymphocytes decrease…

Answer 12

shift to the left

bacterial infection

Question 13

if lymphocytes increase and neutrophils decrease

Answer 13

shift to the right

viral infection

Question 14

dehiscence and evisceration can happen POD

Answer 14

5-6
wound infection
abdominal distention
edges part slowly with extravasation of pink serous fluid

Question 15

Interventions for evisceration

Answer 15

cover with saline
increase IV
monitor for shock-stay with patient
call Dr

Question 16

what is the antidote for heparin

Answer 16

protamine sulfate

Question 17

anticoagulant therapy for DVT

Answer 17

heparin
LMWH - fragmin, lovenox
xarelto (rivaroxaban)

Question 18

what are the site for heparin and LMWH

Answer 18

abdomen

iliac crest

Question 19

subcutaneous injection of LMWH-Fragmin, Lovenox

Answer 19

keep air bubble
sites abdomen or iliac crest
DO NOT aspirate
hold skin fold during injection 
DO NOT rub site

Question 20

when giving heparin subcutaneously

Answer 20

abdomen or iliac crest
rotate sites
DO NOT aspirate
hold skin fold during injection
DO NOT rub site

Question 21

what is are the therapeutic effects of LMWH

Answer 21

no lab measurements required

fixed doses per weight (1 mg/kg)

Question 22

therapeutic effects of heparin

Answer 22

PTT normal 24-36 sec, therapeutic 46-70 sec

ACT normal 80-135 sec, therapeutic 3 min

Question 23

what are the therapeutic effects of warfarin (Coumadin)

Answer 23

INR daily
normal .75-1.25, therapeutic 2-3

levels take 48-72 hours (3-5 days)

Question 24

drug interactions with warfarin

Answer 24

barbiturates (phenobarb)
NSAIDS
dilantin 
herbal supplements
food-green leafy vegetables

Question 25

defining characteristics of pulmonary emboli

Answer 25

``` sudden sharp chest pain extreme apprehension intense hyperventilation intense dyspnea cough hemoptysis decrease PO2 increase CO2 ```

Question 26

Packed RBCs (PRBC)

Answer 26

prepared from whole blood 1 unit =250-300 ml less risk of fluid overload increase RBC mass for anemia, platelets not functional

Question 27

Frozen RBCs

Answer 27

prepared from RBCs Can be stored for 10 years after thawing use within 24 hrs used in autotransfusion

Question 28

Platelets

Answer 28

prepared from whole blood 1 unit =30-60 ml used for bleeding disorders

Question 29

Fresh Frozen plasma

Answer 29

``` liquid portion of whole blood 1 L = 200-250 ml rich in clotting factors no platelets used for bleeding disorders, low Vit K use 2 hrs after thawing ```

Question 30

Albumin

Answer 30

``` prepared from plasma cause water shift from extravascular to intravascular space used to tx hypovolemic shock used for someone with low BP and edema increase BP and decrease edema hypoalbuminemia ```

Question 31

S&S of transfusion reaction

Answer 31

``` itching hives swelling SOB fever chills ```

Question 32

S&S of adverse reaction to transfusion

Answer 32

``` restlessness hives nausea vomiting torso or back pain chills fever hematuria SOB flushing ``` Stop transfusion immediately, notify physician

Question 33

When should the nurse change the blooding during transfusion

Answer 33

after every 2 units transfused to decrease chance of bacterial contamination.

Question 34

when should the blood be spiked

Answer 34

30 min of arriving on the floor | should be infused within 4 hrs

Question 35

blood transfusion reactions acute hemolytic

Answer 35

``` chills fever low back pain tachycardia dyspnea hypotension dark urine shock ``` Tx: Stop transfusion

Question 36

Febrile transfusion reactions

Answer 36

``` sensitization from donor sudden chills increase temp headache anxiety muscle pain ``` Tx. Stop transfusion

Question 37

mild allergic reaction during a blood transfusion

Answer 37

sensitivity to foreign plasma proteins flushing hives (urticaria) Tx: antihistamines (Benadryl) and continue with transfusion slowly

Question 38

Blood transfusion reactions-anaphylactic

Answer 38

``` sensitivity to donor plasma proteins Anxiety urticaria (hives) dyspnea wheezing ``` Tx: stop transfusion and treat symptoms (epinephrine)

Question 39

blood transfusion reaction-circulatory overload

Answer 39

``` cough SOB dyspnea headache pulmonary congestion hypertension tachycardia distended neck veins (first sign) ``` Tx: adjust flow rate increase HOB give diuretics and O2 as ordered

Question 40

blood transfusion reaction - sepsis

Answer 40

``` bacterially infected blood rapid onset of chills fever vomiting diarrhea hypotension shock ``` Tx: stop transfusion, draw blood cultures, and send to lab with remaining transfusion treat symptoms

Question 41

what is the leading cause of trans-related death

Answer 41

``` reaction B/w transfusion and pt's blood causes pulmonary inflammation fever hypotension tachypnea decrease O2 ``` Tx: stop transfusion, send blood samples chest x-ray O2 and steroid notify Dr.

Question 42

If acute reaction is suspected for blood transfusion

Answer 42

``` stop transfusion infuse saline notify blood bank and MD recheck blood monitor V/S and U.O treat symptoms send blood bag and tubing to blood bank collect required specimens per policy document per policy ```

Question 43

Should the RN pre medicate the patient before a blood transfusion?

Answer 43

No | premedication can mask the beginning of a more serious transfusion reaction.

Question 44

what precaution should the RN take to prevent acute hemolytic transfusion

Answer 44

meticulous attention to detail labeling blood samples and blood components accurately identifying the recipient

Question 45

when does fever R/T febrile during blood transfusion begun

Answer 45

within 2 hours of transfusion

Question 46

Can antipyretics be given to prevent fever before blood transfusion

Answer 46

yes