356 Exam 3

Blood transfusions

-0.9% NS usually used (dextrose can lead to clumping of RBC's)- Start IV before obtaining blood product, transfusion must begin within 30 mins of release from blood bank -2 RN's need to compare and validate: unit number match, ABO group and Rh type are the same, expiration date, 2 pt identifiers, clots, sign of contamination of the bag -Obtain baseline VS before beginning and then 5-15 minutes after infusion started

A pt has to receive an order of 1 unit of packed RBC's. The nurse will make sure to administer which of the following with the order

0.9% saline

A client has been diagnosed with a gastrointestinal bleed and the health care provider has ordered a transfusion. At what rate should the nurse administer the client's packed red blood cells?

1 unit over 2-3 hours. No longer than 4 hours

Phlebitis grading

1: Erythema at site with or without pain 2. Erythema, edema, and pain 3: Grade 2 with a streak formation and palpable venous cord 4: Grade 3 with a palpable venous cord 1+ inch and with purulent drainage

The nurse is teaching a healthy adult client about adequate hydration. How much average daily intake does the nurse recommend?

2500 mL/day

Transfusion must be completed within ______ hours

4 hours

Intradermal injections are given at ____ angle?

5-15 degree

Characteristics of Thrombophlebitis

Blood clot Signs: Similar to phlebitis, IV flow can also cease in clot is obstructing needle Interventions: Stop immediately, apply warm compress (if ordered), DO NOT rub or massage site

Hemolytic transfusion reactions

Caused by incompatible blood type or Rh incompatibility. -Low back pain -Hypotension -Tachycardia -Fever and chills -Chest pain -Tachypnea -Hemoglobinuria

What are these characteristics a sign of and how should they be fixed? Dyspnea, dry cough and pulmonary edema

Circulatory overload Intervention: Slow or stop infusion; monitor VS; notify HC provider; place pt in upright position with feet dangling

Which of the following nursing process is a nurse using when analyzing pt data to determine a pt's strengths following a CVA?

Diagnosing

Characteristics of Extravasation

Escaping of fluid into surrounding tissue, more serious than infiltration Signs: Pain, burning, swelling, blanching, coolness, blisters (late sign) Nursing Interventions: Stop IV immediately. Administer antidote if one available. Cold compress. Elevate extremity

Characteristics of infiltration

Escaping of fluid into the subcutaneous tissue Signs: -Edema, pallor, coldness, pain, decrease of flow rate, tenderness, hardness, leakage at site Nursing Interventions: Remove IV line. Elevate extremity. Warm or cold compress depending on IV fluid

True/False: Molecules in the body's chemical compounds that remain intact are called electrolytes

False Rationale: They would be nonelectrolytes

Early signs of transfusion reaction

Flushing, dyspnea, itching, hives or rash or unusual comments

Local IV therapy complications

Hematoma: Vein is "blowing", which means a small hole was made in the vein and blood is extravasating outward. Remove immediately Infiltration Extravasation Phlebitis Thrombophlebitis Infection Nerve injury : Could happen if an artery was inadvertently used. IV in the ventral part of hand can cause nerve injury

Which statement accurately describes appropriate nursing interventions in unexpected situations when removing a peripherally inserted central catheter (PICC)?

If a portion of the catheter breaks when removing it, apply a tourniquet to the upper arm and notify the health care provider.

Characteristics of Phlebitis

Inflammation of a vein wall Signs: Pain, edema, erythema, warmth, redness traveling along vein Interventions: Remove IV line. Cold compress initially (can be delegated to UAP), then a warm compress

What does "on call" basis mean?

Medications will be given when the OR staff notify the nurse to

Which finding indicate fluid volume excess?

Moist crackles heard upon auscultation

What is the nurses priority assessment prior to infuse 1 unit of blood

Obtain baseline VS

An older adult has fluid volume deficit and needs to consume more fluids. Which approach by the nurse demonstrates gerontologic considerations?

Offer small amounts of preferred beverage frequently

Which method of documentation is unique in that it does not develop a seperate care plan but instead incorporates the care plan into the progress notes?

PIE (problem, intervention, evaluation)

The nurse is responding to a client's call light. The client states, "I was getting out of bed and caught my IV on the siderail. I think I may have pulled it out." The nurse determines that the intravenous (IV) catheter has been almost completely pulled out of the insertion site. Which action is most appropriate?

Remove IV catheter and reinsert in another location

Systemic IV therapy complications

Septicemia Fluid Overload Air Embolus Catheter Embolus Signs of systemic: Chills, fever, tachycardia

Fluid overload with IV therapy

Too large of volume is infused Signs: Engorged neck veins, hypertension, dyspnea Result in: Cardiac or respiratory failure. Monitor I & O and V.S., Assess for edema, auscultate lung sounds, slow rate of infusion, notify provider

True/False: A hypertonic solution has a greater osmolarity, causing water to move out of the cells and to be drawn into the intravascular compartment, causing cell to shrink

True

True/False: A nurse who fails to log off a computer after documenting pt care has breached pt confidentiality?

True

True/False: Central venous access devices provide access for a variety of IV fluids, medications, blood products, and TPN solutions and allow a means for hemodynamic monitoring and blood sampling

True

True/False: One of the purposes of creating a pt record is to evaluate the quality of care pt's have received and the competence of the nurses providing that care

True

Which statement most accurately describes the process of osmosis?

Water moves from an area of lower solute concentration to an area of higher solute concentration.

Which one of the following electrolyte imbalances occurs due to a sodium deficit in ECF caused by a loss of sodium or gain of water? a. Hyponatremia b. Hypernatremia c. Hypokalemia d. Hyperkalemia

a. Hyponatremia Rationale: Hypernatremia- surplus of sodium in the ECF Hypokalemia- Potassium deficit in ECF Hyperkalemia- Excess of potassium in ECF

While removing a client's peripherally inserted central catheter (PICC), part of the catheter breaks off. What action is the nurse's priority?

apply tourniquet to the clients upper arm

A preoperative nurse is preparing the pt for surgery. Which final safety intervention will the nurse do a. Allow family to walk pt to OR b. Remove pt dentures and contact lens c. Prepare surgical suite for operation d. Assist pt to complete a living will

b

What is the most important reason for controlling postoperative nausea/vomiting in the PACU? a. prevent dehydration b. prevent airway issues c. prevent surgical dressing from becoming soiled d. prevent pt from becoming upset

b

Which intervention should the nurse delegate to the unlicensed nursing assistant when caring for a client with acute pain? a. Bring pain medication to room b. Apply ice pack to site of pain c. Check on pt 30 minutes after administering pain medication d. Observe the pt's ability to use the PCA

b

The nurse is caring for a male client who has a diagnosis of heart failure. Today's laboratory results show a serum potassium of 3.2 mEq/L (3,2 mmol/L). For what complications should the nurse be aware, related to the potassium level?

cardiac dysrhythmias

A client's most recent blood work indicates a K+ level of 7.2 mEq/L (7.2 mmol/L), a finding that constitutes hyperkalemia. For what signs and symptoms should the nurse vigilantly monitor?

cardiac irregularities

A client who is NPO prior to surgery reports feeling thirsty. What is the physiologic process that drives the thirst factor?

decreased blood volume and intracellular dehydration

A client is taking a diuretic such as furosemide. When implementing client education, what information should be included?

decreased potassium levels

A nurse is reinforcing wound edges and applying a blinder to the separated incisions of a client after a surgery. Which postoperative complication has the client developed?

dehiscence

The recovery nurse is caring for a surgical client in the PACU. The client's blood pressure is dropping and the heart rate is increasing. The nurse suspects the client is:

developing shock

A nurse who has diagnosed a client as having "fluid volume excess" related to compromised regulatory mechanism (kidneys) may have been alerted by what symptom?

distended neck veins

A client is to receive a blood transfusion. Immediately after initiating the transfusion, the nurse suspects that the client is experiencing a hemolytic reaction based on which finding? Select all that apply.

fever, facial flushing, low back pain, hematuria

The student nurse asks, "What is interstitial fluid?" What is the appropriate nursing response?

fluid in the tissue space between and around cells

A client who is admitted to the health care facility has been diagnosed with cerebral edema. Which intravenous solution needs to be administered to this client?

hypertonic solution

Sodium: 138 mEq/L (138 mmol/L)Potassium: 3.2 mEq/L (3.2 mmol/L)Calcium: 10.0 mg/dL (2.5 mmol/L)Magnesium: 2.0 mEq/L (1.0 mmol/L)Chloride: 100 mEq/L (100 mmol/L)Phosphate: 4.5 mg/dL (2.6 mEq/L) whats the imbalance

hypokalemia

A client with protracted nausea and vomiting has been receiving intravenous solution at 125 ml/h for the past several hours. The administration of this solution has resulted in an increase in blood pressure because the water in the solution has passed through the semipermeable membrane of blood cells, causing them to swell. What type of solution has the client been receiving?

hypotonic solution

A client who is scheduled to undergo coronary bypass surgery in a week asks the nurse whether he should discontinue taking his cholesterol medicine ahead of the surgery. Which should be the nurse's response?

i will need to check with your HCP about that

A client with a diagnosis of colon cancer has opted for a treatment plan that will include several rounds of chemotherapy. What vascular access device is most likely to meet this client's needs?

implanted CVAD

A client had an open cholecystectomy (gallbladder removal) 36 hours earlier, and the nurse's assessment this morning confirms that the client has not yet had a bowel movement since prior to surgery. How should the nurse best respond to this assessment finding?

monitor pt closely and promote fluid intake

A nurse monitoring a client's IV infusion auscultates the client's lung sounds and detects crackles in the bases in lungs that were previously clear. What would be the most appropriate intervention in this situation?

notify primary provider asap for possible fluid overload

The nurse is administering intravenous (IV) therapy to a client. The nurse notices acute tenderness, redness, warmth, and slight edema of the vein above the insertion site. Which complication related to IV therapy should the nurse most suspect?

phlebitis

Characteristics of Local Infection

redness, pus, warmth, induration, and pain Caused by: Poor aseptic technique that can allow bacteria to enter the needle, catheter insertion site, or the tubing connection

A client has been receiving intravenous (IV) fluids that contain potassium. The IV site is red and there is a red streak along the vein that is painful to the client. What is the priority nursing action?

remove IV

A nurse is preparing the site for insertion of a peripheral venous catheter using chlorhexidine. Which actions would be appropriate for the nurse to do? Select all that apply.

rub in side to side rub in back and forth motion

A nurse is providing care to a client with an extracellular fluid (ECF) volume deficit. The nurse suspects that the deficit involves a decrease in vascular volume based on which finding? Select all that apply

slow-filling peripheral veins decreased urine output orthostatic hypertension

A client is diagnosed with hypovolemia after significant blood loss. Which action will the nurse take?

start an IV of 0.9% NS

The nurse is monitoring a blood transfusion for a client with anemia. Five minutes after the transfusion begins, the client reports feeling short of breath and itchy. Which action should the nurse take?

stop transfusion and notify the HCP

In which position would the surgical nurse place a client undergoing minimally invasive surgery of the lower abdomen or pelvis?

tredelenburg