Week 1 Flashcards
1
Q
platelet transfusion
A
does not need to match blood type
idicated for platelets <20k
200 to 300 ml. (15/30min total)
small filter, short tubing
2
Q
plasma transfusions
A
match ABO blood type
frozen upon transfusion
infuse 200 ml FFP over 30-60 min
Y-set or straight filtered tubing
3
Q
WBC transfusion
A
risk for severe reaction
400ml over 45 to 60 min provider presence
**amhotericin b *
4
Q
amphotericin b antibiotics & wbc transfusion
A
wait 4-6hrs for admin – will hemolyze wbc
5
Q
what to do in acute hemolytic transfusion reaction
A
result of incompatible blood
- stop infusion
- assess
- initiate 0.9% NaCl w new tubing
6
Q
signs & symptoms of acute hemolytic transfusion reaction
A
fever
chills
lower back pain
dark urine
tachycardia / tachypnea
flushing
hypotension
chest pain
nausea
anxiety
impending doom
7
Q
circulatory overload occurs when & nursing actions
A
transfusion rate is too fast
- slow transfusion
- elevate head of bed & postion client upright w feet lower than heart
- admin meds (*diuretic but check K+ first)
8
Q
s/s of circulatory overload
A
SOB
hypertension
crackles
cough
dyspnea
jugular vein distention
tachycardia
9
Q
in the first 15-30 minutes of a blood transfusion, a nurse must
A
stay with the client and assess vitals every 15 min
10
Q
before blood transfusion a nurse must (7):
A
- assess lab values & verify order/consent
- verify type & crossmatch
- initiate large bore IV access
- explain reason for transfusion
- Inspect blood product
- prime w/ 0.9% NaCl
- verify client & compatibility w 2 RN’s
11
Q
in an autologous transfusion
A
client’s can donate their own blood 6 weeks prior to surgery
12
Q
salvage blood re-infusion
A
must occur within 6 hours of collection
13
Q
BUN range
A
6 to 24 mg/dl
14
Q
hematocrit ranges
A
women 36% to 48%
men 40% to 54%
15
Q
s/s of hypovolemia
A
tachycardia / tachypnea
hypotension
hypothermia
**low-grade fever
decreased skin tugor
n/v/c
16
Q
lab values indicating hypovolemia
A
*INCREASED values
Hct/Hgb
BUN
sodium
urine specific gravity
blood osmolality
17
Q
4 nursing actions for hypovolemia
A
- monitor I&O
- vitals & loc
- weight - 8hrs
- gait & movement
18
Q
4 nursing actions for hypovolemic shock
A
- administer O2
- vitals every 15 min
- fluid replacement
- vasoconstrictors / (+) inotropic meds
19
Q
s/s of hypervolemia
A
tachycardia / tachypnea
hypertension
crackles
cough
weakness
cool skin
edema
distended neck veins (jugular)
20
Q
lab values indicating hypervolemia
A
*DECREASED LABS
Hct / Hgb
BUN
urine specific gravity
blood osmolality
21
Q
2.2 lbs / 1kg of weight loss = how much fluid loss
A
1L
22
Q
2 nursing actions for hypervolemia
A
- monitor I & O
- assess breathing
23
Q
3 nursing actions for pulmonary edema
A
- position client in high-fowler’s
- administer oxygen
- morphine, nitrates, & diuretics
24
Q
calcium range
A
9.0 to 10.5
25
magnesium range
1.3 to 2.1
26
chloride range
98 to 106
27
phosphorus range
3.0 to 4.5
28
s/s of hyponatremia
hypotension
hypothermia
hyperactive bowel
tachycardia
confusion
muscle weakness/ twitching
edema
*relates to hypervolemia
29
lab values indicating hyponatremia
DECREASED
*sodium
*urine specific gravity
* blood osmolarity
30
replacement sodium should not exceed the rate of
12 mEq/L in 24 hours
31
saline solution for hyponatremia
lactated ringer
0.9% isotonic saline
32
s/s of hypernatremia
hyperthermia
thirst
hypotension
tachycardia
muscle weakness
dry mucous membranes
33
lab values for hypernatremia
*INCREASED
sodium
blood osmolality
urine specific gravity
34
potassium values
inverse w sodium
3.5 to 5
35
s/s of hypokalemia
*flat T-wave
hypotension
n/v/ constipation
HYPOactive bowel
shallow breathing
lethargy
increased risk for digoxin toxicity
36
potassium should be administered at a rate of
10 mEq/L
37
s/s of hyperkalemia
*peak T-wave
hypotension
flaccid paralysis
diarrhea
HYPERactive bowel
oliguria
can cause metabolic acidosis
associated with diabetic keto-acidosis
38
Meds for excretion when dealing w hyperkalemia
loop diuretics (furosemide)
sodium polystyrene sulfonate
albuterol (beta2 agonist)
patiomer
39
s/s of hypocalcemia
HYPERactive bowel
diarrhea
abdominal cramps
parathesia of fingers/lips
low vitamin D
impaired clotting time
(+) chovstek (face twitch)
(+) trosseau's (bp cuff & hand spasm)
40
nursing considerations for hypocalcemia
Vitamin D supplements
seizure precautions
low stimulation
*calcium gluconate if severe
41
s/s of hypomagnesemia
<1.3
constipation
HYPOactive bowel
paralytic ileus
(+) chovstek (face twitch)
(+) trosseau's (bp cuff & arm)
42
medication to reverse hypermagnesemia
calcium gluconate
43
medication for hypomagnesemia
oral magnesium sulfate
(iv if severe)
44
nursing interventions for hypokalemia
assess hand grasps for muscle weakness
assess deep tendon reflexes
45
a nurse is caring for a client who has a nasogastric tube attached to low-intermittent suctioning. the nurse should monitor for which of the following electrolyte imbalances?
1. hypercalcemia
2. hyponatremia
3. hyperphosphatemia
4. hyperkalemia
2. hyponatremia
46
antidote for benzo's (-pam/lam)
flumazenil
47
8 nursing actions for malignant hyperthermia
1. stop surgery
2. protect airway = admin100% O2
3. admin dantrolene (muscle relaxant)
4. assess ABG's (risk for hyperkalemia)
5. infuse ice IV 0.9% NaCl
6. apply cooling blanket
7. insert indwelling catheter
8. monitor
48
s/s of malignant hyperthermia
extreme temp elevation
hypotension
tachycardia
muscle rigidity
myoglobinuria
49
a nurse is caring for a client who reports a headache following an epidural regional nerve block. which of the following actions should the nurse take?
1. decrease the client's fluid intake
2. apply pressure to the puncture site
3. place the head of the bed flat
4. instruct the client to lie prone
3. place the head of the bed flat
50
reversal agent for opiods
naloxone
51
pre-op assessment includes (5)
1. detailed history
2. allergies
3. anxiety level
4. vitals & head to toe
5. venous thromboembolism risk
52
ati NPO rules for surgery
6hrs = solid food
2 hrs = clear liquid
53
nursing considerations for prophylactic antibiotics
1. have client void before taking them
2. admin ONE HOUR before surgery
54
4 pre-op nursing actions
1. WITNESS informed consent
2. chart last time client ate/drank
3. admin heart meds b4 surgery
*****beta-blockers
4. apply anti-embolism stockings
55
BMi range
18.5 to 24.9
56
a nurse is caring for a client who manifests indications of hypovolemia while in the PACU. Which of the following findings requires actions by the nurse? sap
1. urine output less than 25 mL/hr
2. Hematocrit 53%
3. BUN 24 mg/DL
4. tenting of skin over the sternum
5. apical pulse rate of 62/min
1. urine output less than 25 mL/hr
2. Hematocrit 53%
3. BUN 24 mg/DL
4. tenting of skin over the sternum
57
a nurse is caring for a client who reports n/v 2 days post-op following a hysterectomy. Which of the following actions should the nurse perform first?
1. assess bowel sounds
2. administer an antimimetic med
3. restart prescribed IV fluids
4. Insert a prescribed NG tube
1. assess bowel sounds
58
priority in post- op
A - AIRWAY
B- BREATHING
C- CIRCULATION
59
nursing actions for unresponsive post op patient
*lateral position (aspiration)
*no knee under the pillow (venous return)
60
4 nursing actions for paralytic illeus
1. monitor bowel function
2. encourage ambulation
3. admin METOCLOPROMIDE
4. NG tube prn
61
2 considerations for older adults w IV therapy
1. blood pressure cuff instead of tourniquet
2. hand below heart level
62
Infiltration & 4 nursing actions
*cool skin, edema, swelling, & pallor
1. stop infusion
2. elevate & encourage ROM
3. cold/warm compress
4. check IV & restart
63
a nurse is assessing the IV catheter insertion site & notes swelling at the site w/ decreased skin temp. which of the following actions should the nurse take? (sap)
1. stop infusion
2. start a new Iv access distal to the site
3. apply warm compress to the insertion site
4. elevate the client's arm
5. Obtain a specimen for culture at the insertion site
1. stop infusion
3. apply warm compress to the insertion site
4. elevate the client's arm
64
platelet units should be administered within
15 to 30 min/unit
65
fresh frozen plasma should be administered
30 to 60 min/unit
*elevated aPTT
66
Whole blood
*transfused over 2 to 4 hours
acute blood loss, dehydration, & shock
66
WBC should be administered within
45 min to 1 hour
67
IV solution used with blood products
0.9% sodium chloride
68
transfusions require ___ & must be completed within ___. while tubiing must be changed every ____
require 2 nurse verification
completed within 4 hours
changed every 2 units
69
blood consideration for older adults
wait 2 hrs between transfusions of multiple units
70
a nurse must document (7) things with blood
1. blood product type
2. blood bank # of product
3. total volume infused
4. time of start/finish
5. vitals
6. adverse effects
7. extra actions taken
71
packed RBS are administered for
anemia
72
a nurse is transfusing packed RBC's to a client w anemia. client reports a sudden headache & chills. client's temp is 2 degrees higher than baseline. In addition to notifying the provider. which additional actions should the nurse take? sap
1. stop the transfusion
2. place the client in an upright position w feet down
3. remove the blood bag and tubing from the iv catheter
4. obtain a urine specimen
5. infuse 5% dextrose in water through the IV
1. stop the transfusion
3. remove the blood bag and tubing from the iv catheter
4. obtain a urine specimen
73
a nurse is assessing a client through a transfusion of a unit of whole blood. the client develops a cough, sob, elevated BP, & distended neck veins. the nurse should expect a prescription for which of the following meds.
1. diphenhydramine
2. epinephrine
3. furosemide
4. lorazepam
furosemide --- circulatory overload
74
ongoing assessments when post-op
1. Neuro = LOC, GCS, reflexes & movement
2. Pain level
3. I & O
4. Bowel sounds & abdominal distention
5. dressing & drainage
75
treating post-op paralytic illeus
1. offer ice chips first
2. water second
3. ambulation
4. prokinetic agent
5. NGT to decompress stomach
76
s/s of pneumonia
*post op complication
crackles
INCREASED
- respiratory rate
- temperature
- heart rate
77
s/s of shock
hypotension
tachycardia
decreased urinary output
lethargy
cool & pale skin
78
s/s of venous thromboembolism
redness & edema
warmth
calf tenderness
pain
79
3 types of drains
1. penrose drain (stick)
2. Jackson- pratt (light bulb)
3. hemovac (accordian)
* 30 ml per hour MAX
80
catheter types & must always be flushed with
subclavian vein
internal jugular vein
*10cc flush w normal saline
81
in preventing an air embolism w a CVAD
1. instruct client to hold breath while pulling out
2. reverse trendleberg position
3. head turned away from site
82
phlebitis and nursing actions
course of vein = red, tender, warm, & painful
1. stop infusion
2. flush
3. discontinue & use WARM compress
83
nursing interventions for air embolism
1. clamp catheter
2. position client in left lateral trendelenberg
3. give O2
84
s/s for air embolism
decrease in o2 sat
hypotension
tachycardia
dyspnea
chest pain
85
s/s for pneumothorax & nursing interventions
s/s = dyspnea, chest pain, decreased breath sounds on one side
1. elevate HOB
2. admin O2
3. discontinue catheter
3.notify & assist
86
nursing interventions for catheter related bloodstream infection
1. discontinue catheter
2. apply warm compress
3. culture tip of catheter
4. admin antibiotic & antipyretic
87
blood donation matching
NEGATIVES match w/ negatives (itself & O)
POSITIVES match w/ both (+ & -) of itself
88
INR range
0.7 to 1.8
