Quiz 1 - Modules 1 & 2 Flashcards

Question

Systemic Complications: Speed Shock

Answer 1

Reach toxic levels with medication when introduced too fast in places that are rich in blood Dizziness, chest tightness, flushed, pounding headache, chills, back pain, dyspnea, apprehension

Answer 2

Red, tender IV site, fever, malaise, VS changes

Answer 3

Air traps blood and goes into right ventricle Resp distress, low HR, high BP, cyanosis, change in LOC, wheezes, cough

Answer 4

For extensive IV therapy, poor peripheral access, infusing vesicants, hypertonic solutions, and chemotherapy – high osmolarity or pH extremes * Terminal line ends in Superior Vena Cava: need radiological confirmation of placement or use fluoroscopy * Multiple lumens: to infuse multiple meds, TPN and blood have separate line * Hemodynamic monitoring * Frequent blood sampling Short term: non-tunneled and PICC lines Long term: tunneled and implantable port

Answer 5

Duration: short term (3-10 days) Uses: patients who are unstable Placement: inserted in jugular or subclavian, put patient in trendelenburg for sub, Sutured in place, no sedation for insertion Indications: IV therapy, blood sampling, central venous monitoring Disadvantage: High risk for central line associated bloodstream infection (CLABSI) and pneumothorax

Answer 6

Duration: Short-term (6 weeks-6 months) Uses: IV therapy at home & acute care settings Placement: upper arm (antecubital fossa) to superior vena cava, secured with wound closure strips (not suture since this can create infection), need X-ray to confirm placement Advantages: eliminates risk for pneumothorax, use for all ages, easier to ahve labs drawn, replace only as needed

Answer 7

Duration: Long-Term, permanent device Placement: upper chest wall, antecubital area of arm need radiology to confirm placement Advantages: no visible external port/lines, minimal daily care, good for kids, low risk for infection, improved self-image Disadvantages: discomfort when accessing, inserting needle into skin

Answer 8

Duration: Long-Term Placement: Jugular or subclavian vein, Sutured in place but stitches are removed after 7-14 days, Dacron → seal to prevent bacteria under the skin & prevent dislodgement - takes 3 weeks for catheter to heal Advantages: lower risk for CLABSI, allows for ease of movement

Answer 9

* integrity of dressings * infection * tenderness * measure length of exposed catheter

Answer 10

* push-pause method * use 10mL or larger syringe - less pressure * 3-5mL of saline before and after * 3mL of heparin 100u for catheter patency * q7 days if not in use

Answer 11

* sterile procedure with masks, gowns, and gloves * change every 24 hrs or when soiled * antimicrobial swab over site for 30 seconds, 2" radius * change caps * change tubing every 24 hours for TPN

Answer 12

Pneumothorax/hemothorax: * Sudden onset of chest pain/SOB due to air accumulation in the lungs * Give oxygen, monitor vitals, pressure on entry site, remove catheter CLABSI * Central line associated bloodstream infection & catheter related bloodstream infection * If WBC low → will not see drainage or pus, will see fever/chills Air Embolism Thrombosis * start IV somewhere else and give warm compress * S/S: fullness in face, swelling Catheter Migration * Occurs when catheter moves from where it was placed * Risks: physical activity, vomiting * Signs: swelling of neck/chest during infusion, pain

Answer 13

* Primary IV bag (directly attached to patient) ○ Piggyback (medication is piggybacked on primary IV infusion) ○ IV push (through a primary line) ○ Syringe pump (either primary line or piggy backed onto primary line) ○ Volume controlled (primary line or piggybacked onto primary line)

Answer 14

* intermittent infusion * IV push directly

Answer 15

* infuses rate faster * clamp tubing above distal port, proximal to patinet * check for blood return * admin slowly

Answer 16

* controls the rate, can program the rate * infuse using distal port on primary line or saline lock * used for peds

Answer 17

Purpose: for peds, small amount of controlled substance, diluted with IV solution, do not fluid overload

Answer 18

* flush with 1-3mL saline before and after for patency * instill flush as same rate as med

Answer 19

One drug is MIXED with another drug/solution to produce a product UNSAFE for administration

Answer 20

REACTION of drug with other drugs/solutions → ALTERATIONS in integrity and potency of active ingredient

Answer 21

Undesirable effect occurring as a result of 2 or more drugs being given concurrently - Can have an increased or decreased therapeutic response

Answer 22

* Baseline vitals, taken periodically once transfusion starts based on protocol * Kidney function, cardiovascular, lung sounds * Evaluate IV site, gauge of needle - 18 gauge needle for rapid, 20 gauge for slow * Blood matches patient * Identify unit label of blood and patient by TWO nurses before hanging blood * Check for expiration by TWO nurses (both nurses must document that check occurred) * need Y set filters and normal saline

Answer 23

* Pump can inform us of phlebitis, easier for 4 hour period * Infuse slowly: Large enough dose that can alert the nurse of a reaction but small enough that it can be successfully treated * If pt shows signs of an adverse reaction, transfusion is stopped IMMEDIATELY & hang NS alone in separate tubing * After 15 mins have passed safely, flow rate can be increased * RBCs should be infused within a 4 hour period * RBCs should be hung within 30 mins of obtaining from blood bank

Answer 24

Group A – Recipient Antigens A – Antibodies present – Anti B Group B – Recipient Antigens B – Antibodies present - Anti A Group AB – Recipient Antigens A&B – Antibodies none Group O – Recipient Antigens none – Antibodies Anti A and B

Answer 25

Within 1 hr S/S: Urticaria, localized erythema, facial flushing, dyspnea, wheezing Nursing Action: Pause transfusion, keep vein open, notify provider, monitor vital signs, administer antihistamine orders (or benadryl 30 mins before)

Answer 26

Within 1 hr S/S: Anxiety, hypotension, shock, wheezing, urticaria Nursing Actions: Discontinue transfusion, keep vein open with just NS, administer CPR, anticipate order for steroids, maintain BP; prevention using well washed RBCs where plasma has been extracted

Answer 27

Reactions to antibodies directed against leukocytes/platelets Occurs immediately or 1-2 hours after transfusion is completed PreventionL use leukocyte-reduced blood components S/S: fever, chills, N/V/headache, tachycardia, nonproductive cough Nursing Actions: Discontinue transfusion, Keep vein open with NS, notify provider, monitor vitals, administer antipyretic

Answer 28

Most life-threatening Occurs after infusion of incompatable RBCs Leads to activation of coagulation system and release of vasoactive enzymes that result in vasomotor instability, cardiorespiratory collapse, and DIC Prevention: extreme care in identification process S/S: fever, Lumbar, Flank, Chest Pain, flushing of face, tachycardia Nursing Actions: stop transfusion, disconnect tubing, infuse saline, call provider, monitor need for dialysis