Med Surg II Exam 2

how much time do you have to start a blood transfusion after picking up blood from the blood bank?

30 minutes

what helps prevent dislocation of a new hip joint in pts. post hip replacement?

abduction of the hips

the nurse is caring for a patient with megaloblastic anemia and nutritional deficit. The nurse should know that this patients health problem is due to what? production of inadequate quantities of RBCs premature release of immature RBCs injury to the RBCs in circulation abnormalities in the structure and function RBCs

abnormalities in the structure and function RBCs - the RBCs are too large that they can get trapped while still in the bone marrow

antiplatelet agents

aspirin, clopidogrel (plavix), Brillinta, effient

what should the nurse do before transfusing a pt. with PRBC?

assess pt. vitals to establish baselines

Signs of melanoma (ABCD)

asymmetry, border irregularity, color variation, diameter (> 6mm), evolving (changes to it)

what factors should pts with sickle cell avoid to prevent exacerbations?

avoid cold temperatures & ensure sufficient hydration

The nurse is monitoring for fluid and electrolyte changes in the emergent phase of burn injury for a patient. Which of the following will be an expected outcome?

base-bicarbonate deficit elevated hematocrit sodium deficit

causes of iron deficiency anemia

blood loss, prior GI malabsorption of iron, and/or inadequate iron intake

which diagnostic test is used on osteoporosis patients to detect fractures?

bone densitometry

Which type of burn injury involves destruction of the epidermis and upper layers of the dermis as well as injury to the deeper portions of the dermis?

deep partial-thickness

a blood transfusion is going slower than expected and has reached 4 hours. what should the nurse do?

discontinue to the administration and notify the physician - after 4 hours there is a higher risk for infection, so the infusion needs to be continued at that time.

A nurse helps a health care provider treat a full-thickness burn on a patient's hand. Prior to treatment, the nurse documents the appearance of the wound as:

dry and pale

how is external otitis treated?

ear drops

what is one of the biggest indicators of hematologic disease?

extreme fatigue

what is a significant complication secondary to longterm anemia?

heart failure

what are expected lab findings in a patient who has sustained burn injuries and is in the emergent/resuscitative phase of recovery?

hyperkalemia, hyponatremia, elevated hematocrit and metabolic acidosis

why is an escharotomy done?

impaired tissue perfusion

what is the goal of an escharotomy?

improved circulation

how to prevent osteoporosis?

increased calcium & vitamin D intake; participation in regular weight-bearing exercise (walking 3-5 times per week); lifestyle modification - reduced intake of caffeine, tobacco, soft drinks, and alcohol

for a pt. with anemia, when the body senses low levels of oxygen, it's response is:

increased production of erythropoietin

pt has pica, fatigue, low serum iron and low ferritin. what is suspected?

iron deficiency anemia

a pt. with sickle cell anemia requires frequent blood transfusions. what is a possible risk for pts. receiving chronic blood transfusions? hypovolemia vitamin b 12 deficiency thrombocytopenia iron overload

iron overload - they can quickly acquire more iron than they use

pt. is 1 day post op right hip replacement. How should the nurse position the patient? keep their hips in abduction at all times keep hips flexed at no less than 90 degrees elevate the HOB to high fowlers seat the pt in a low chair asap

keep their hips in abduction at all times - by using an abductor pillow HOB shouldn't be more than 60 degrees & their hips should be HIGHER than their knees - so high seat chairs should be used

last typical sign in acute compartment syndrome?

loss of pulses

when repositioning a patient in balanced suspended traction, the nurse should do what?

maintain consistent traction tension while repositioning

nursing interventions for transfusion-associated circulatory overload?

monitor I&Os administer blood products @ a slower rate potentially administer diuretics during or right after transfusion

myopia

nearsightedness - distance vision is poor but close up vision is normal

open angle glaucoma

no symptoms early on painless loss of peripheral vision halos

how is otitis media treated?

oral antibiotics

Which of the following would indicate the need to increase fluids beyond what is recommended for fluid resuscitation?

Myoglobin in the urine

universal blood donor

O negative

how can diabetics reduce their risk of osteomyelitis?

performing good and proper foot care - they often have neuropathy so they might not feel when they have a diabetic ulcer forming or present, which can quickly turn into osteomyelitis if gone untreated

best positioning for post leg amputee?

prone position for 20-30 minutes x A couple times per day; you want to try to avoid having them lay in bed with the HOB elevated because that will induce contracture of the hips

The nurse is caring for a client 48 hours after their burn injury. Which treatment will the nurse anticipate to reduce the client's risk of mortality?

remove burned tissue

biggest complications for pts with sickle cell disease & sickle cell crises

risk for thrombosis and lack of tissue perfusion; increased risk for infection

Which intervention helps to minimize the risk of further injury to an affected person at the scene of a fire?

roll the client in a blanket

first typical sign in acute compartment syndrome?

sensory perception deficits or paresthesia

closed angle glaucoma

severe pain in eye or forehead redness decreased or blurred vision HA n/v

what are severe reactions to blood transfusions?

vascular collapse, bronchospasm, laryngeal edema, shock, fever, chills and jugular vein distension

what is the antidote for warfarin (coumadin)?

vitmain K

how is the cardiac system affected in anemic patients?

when hemoglobin is LOW, the heart attempts to compensate by pumping faster & harder to deliver more blood to the hypoxic tissues. this increased cardiac workload can cause symptoms of tachycardia, palpitations, dyspnea, dizziness, orthopnea, and exertional dyspnea.

A nurse is caring for a client with skin grafts covering full-thickness burns on the arms and legs. During dressing changes, the nurse should:

wrap elastic bandages distally to proximally on dependent areas

how do you respond if an amputee patient complains of pain in the amputated extremity?

ask the pt to describe the pain and treat it as you would any other pt with pain - but their description of the pain character will help guide you with the right way to treat the pain (depending on etiology)

how do you prevent skin breakdown in skeletal traction?

assess pin insertion sites every 8 hours for inflammation and/or infection; there should be loose coverings over the insertion pins

how do you assess for jaundice or pallor in a darker skinned patient?

assess the roof of their mouth for a yellow appearance and sclera of the eyes

which findings are consistent with a pt. who has neurovascular dysfunction?

absence of feeling, capillary refill of 4-5 seconds, and cool skin

what is priority after providing cardiovascular stabilization in a burn patient?

addressing fluid status & fluid resuscitation

fibrinolytic agents

alteplase (activase), reteplase (Retavase), urokinase

foods rich in vitamin b12

animal products, eggs, fish, nuts, dairy products, dried beans, citrus fruits, leafy greens

intervention to cool a burn?

apply cool moist towels to the burn

T/F: incontinence associated dermatitis is a pressure injury

false

hyperopia

farsightedness - can see objects far away but not close up

what helps prevent contractures in leg amputee patients?

firm mattress, prone positioning, muscle strengthening exercises

signs & symptoms of transfusion-associated circulatory overload

fluid overload, bounding pulse, hypertension, bounding pulse, restlessness, confusion, JVD, dyspnea

A client is brought to the ED with burns exceeding 20% of total body surface area. Which is the primary nursing intervention in the care of this client

fluid resuscitation

A patient has a burn injury that has destroyed all of the dermis and extends into the subcutaneous tissue, involving the muscle. This type of burn injury would be documented as which of the following?

full thickness

RBCs consist primarily of:

hemoglobin

Immediately after a burn injury, electrolytes need to be evaluated for a major indicator of massive cell destruction, which is:

hyperkalemia

if a pt has their spleen removed or has decreased spleen function, what are they at risk for?

infection

most common cause of death in acute leukemias?

infection or bleeding

a pt has a leg cast and uses a pencil to itch underneath the cast. How should the nurse respond?

instruct the pt not to scratch (to prevent skin breakdown or damage to the cast) and obtain order for antihistamines if needed for itching

are muscle, bone, and/or tendon exposed in a stage 3 pressure injury?

no

is slough or eschar present in stage 2 pressure injuries?

no

is the patients room number a form of identification to verify blood?

no

foods high in iron

organ meats (liver), other means, beans, leafy green vegetables, raisins and molassess

The nurse is caring for a patient who sustained a major burn. What serious gastrointestinal disturbance should the nurse monitor for that frequently occurs with a major burn?

paralytic ileus

what would be an expected finding in pts who have platelet levels under 20,000?

petechiae

what is the antidote for heparin?

protamine sulfate

what should the nurse prioritize in educating patients on prior to blood product transfusions?

signs & symptoms of transfusion reactions

Risk factors for osteoporosis

small frame, female gender, caucasian ethnicity

tissue loss extends into the dermis

stage 2 pressure injury

full thickness loss with adipose tissue visible

stage 3 pressure injury

important education for osteomyelitis patient?

stress on the affected limb should be avoided

what is needed for the proper synthesis of vitamin D?

sunlight

Which of the following is to be expected soon after a major burn?

tachycardia hypotension anxiety

where does blood cell production take place?

the bone marrow

which describes the etiology of a hemolytic transfusion reaction? antibodies to donor leukocytes remained in the blood the donor blood was incompatible with that of the pt the pt had a sensitivity reaction to a plasma protein in the blood the blood was transfused too quickly & overwhelmed their circulatory system

the donor blood was incompatible with that of the patient

what should the nurse educate a patient who is taking iron supplements on?

their stool may become darker in color, they should take iron on an empty stomach since it's absorption can be affected by food (especially dairy) & they should increase their vitamin c intake as that helps enhance iron absorption

education for glaucoma patients?

they will have to use their eyedrops for LIFE ** you CANNOT combine the eyedrops wait 5-10 minutes after installation of one drop before instilling the other to avoid dilution teach pt. to blot corner of their eye to prevent systemic absorption instruct pt to never skip doses educate pt on the systemic and ocular side effects of their medications

what is a normal age-related change to hematologic function in older adults?

they're less able to increase their blood cell production when demand suddenly increases

how long do you stay with a patient after starting a blood transfusion & why?

15-30 minutes; that is the most likely time that they would have a blood transfusion reaction

what is the maximum time allowed for a blood transfusion before you have to discontinue it?

4 hours

Acticoat antimicrobial barrier dressings used in the treatment of burn wounds can be left in place for which time frame?

5 days

Universal blood recipient

AB+

if the nurse suspects iron deficiency anemia they would order which labs:

CBC and fecal occult test

stage 4 pressure injury

Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer

A person suffers leg burns from spilled charcoal lighter fluid. A family member extinguishes the flames. While waiting for an ambulance, what should the burned person do?

Have someone assist him into a bath of cool water, where he can soak intermittently while waiting for emergency personnel

what labs values need to be monitored for patients on warfarin (coumadin) - anticoagulant?

INR

how is pain controlled during the acute phase of burn recovery?

PCA, opioids, etc.

A client who has sustained burns to the anterior chest and upper extremities is brought to the burn center. During the initial stage of assessment, which nursing diagnosis is primary?

Risk for Impaired Gas Exchange

most common bacterial cause of osteomyelitis?

Staph aureus

An explosion of a fuel tanker has resulted in melting of clothing on the driver and extensive full-body burns. The client is brought into the emergency department alert, denying pain, and joking with the staff. Which is the best interpretation of this behavior?

The client has experienced extensive full-thickness burns

complication of vertebral fractures?

constipation - from the medications used to treat the pain & prolonged immobility

The most important intervention in the nutritional support of a client with a burn injury is to provide adequate nutrition and calories to

decrease catabolism.

A client received burns to his entire back and left arm. Using the Rule of Nines, the nurse can calculate that he has sustained burns on what percentage of his body?

27%

Which of the following is the effect of protein catabolism in a client with severe burns?

It compromises wound healing and immunocompetence

a pt has decreased erythropoietin secondary to renal failure. upon examining their CBC, what will the nurse expect to find? increased hemoglobin, decreased hematocrit decreased hemoglobin & hematocrit decreased MCV and red cell distribution width (RDW) increased MCV and RDW

decreased hemoglobin and hematocrit MCV and RDW are not affected because in this case the erythrocytes are still normal in appearance

what determines whether or not a pt will have a systemic response to their burn injuries?

total body surface area affected by the burn

what stage pressure injury for wounds with eschar or slough?

unstageable