Exam 4 spring
Normal digoxin level
0.8-2. (Di means two, don't go above 2)
During the administration of whole blood, a client begins to complain of SOB. The nurse notices JVD, bibasilar crackles, and tachycardia. Prioritize the following nursing actions.
1) elevate HOB to 45 degrees 2) apply oxygen via NC 3) reduce flow rate of the transfusion 4) administer furosemide per MD order 5) document findings in the client record
A transfusion of packed red blood cells is ordered for a client with anemia. List the actions in the order the nurse should preform them.
1) ensure the client signed a consent for the blood transfusion 2) determine the clients vital signs 3) verify that the number on the blood product, laboratory record, and clients wristband match. 4) don a pair of clean gloves 5) start the transfusion slowly
A client with gastric hemorrhage is scheduled to receive two units of whole blood. List the nurse's activities in the order they will be performed when administering a blood transfusion.
1) verify but any type and cross match has been sent to the laboratory 2) obtain venous access preferably with a 19 gauge or larger larger 3) prime the infusion tubing set tubing with normal saline at the bedside 4) ask another nurse to check Play blood identification of the clients bedside
Normal HCO3 range
22-26 mEq/L
Which of the following requires intervention?
300 mL output in 24 hours
Normal CO2 of blood
35-45 mmHg
Normal pH of blood
7.35-7.45
Normal SaO2 range
80-100
Digoxin is not given if the pulse is below
90-110 for infants and young children 70 in older children
Monitor K levels carefully
A fall in the serum potassium level enhances the effects of digitalis, increasing the risk for digoxin toxicity. Increased serum potassium levels diminish digoxin's effect.
universal recipient
AB positive
Kawasaki disease
Acute system vasculitis of unknown cause CRASH and burn: Conjunctivitis Rash Adenopathy Strawberry tongue Hand and feet edema/desquamation Burn - fever - Labs: ALT elevation, thrombocytosis, leukocytosis - Rx: IVIG and aspirin, get echo
TACO interventions
Administer diuretics Slow transfusion Monitor i&o
What is the priority nursing assessment for the client admitted to the PACU?
Airway and gas exchange
Reaction displays: urticaria, itching, bronchospasm
Allergic
A client receiving a blood transfusion complains of itching and difficulty breathing. The heart rate has increased and the blood pressure is falling. Which type of shock would the nurse suspect the client is experiencing?
Anaphylactic
After the surgery the client is taken to PACU, The endotracheal tube is removed and the client responds to their name. During this time in the PACU, the student nurse Monitors the respiratory status closely due to which factors?
Anesthesia can have a depressing effect on respirations The client has hx of smoking The client has an abdominal incision
B+ can receive
B+, B-, O+, O-
Contamination with gram negative organisms
Bacterial
A client resumed a regular diet 72 hours ago and has yet to have a bowel movement. Which is of most concern?
Bowel obstruction
Which is the best indicator of intestinal activity?
Bowel sounds
Symptoms of TACO
Dyspnea, distended jugular vein, hypertension, bounding pulse
AB can donate to A
False.
Reaction displays: chills, tachycardia, fever, hypotension, & tachypnea
Febrile
Benzodiazepine antagonist
Flumazenil
Which of the following diuretics are commonly used to treat heart failure in children?
Furosemide Chlorothiazide Spironolactone
Mild to life threatening reaction with DIC and circulatory collapse
Hemolytic
For which clinical indicator associated with a complication of portal hypertension should the nurse assess the client? 1 Liver abscess 2 Intestinal obstruction 3 Perforation of the duodenum 4 Hemorrhage from esophageal varices
Hemorrhage from esophageal varices
Kawasaki disease tx
High doses of IV immunoglobulin and salicylate therapy Teach parents CPR Continued cardiac follow up
Medicare offers the following resources to client 65 years and older
Home health Skilled nursing services or SNF Hospice
78-year-old client with a diagnosis of CVA is being discharged, what services mighty qualify for under Medicare?
Home health services Skilled nursing services or SNF
Because ACE inhibitors also block the action of aldosterone, the addition of potassium supplements to the drug regimen of patients taking diuretics is usually not needed and may cause
Hyperkalemia
A nurse is caring for a client who is admitted to the hospital with ascites and a diagnosis of cirrhosis of the liver. What does the nurse conclude is the probable cause of ascites?
Impaired portal venous return
HCO3
Kidneys-metabolic
What's the position is best for the semi comatose post operative client?
Left side lying
Medicaid is a state funded government program that offers resources to the following
Low income adults and children Pregnant women Clients with Disabilities
RBC 8, H&H 20/ 55%, WBC 8,000
Low, high, normal
RBC 3, H&H 8/ 30%, WBC 20,000
Low, low, high
CO2
Lungs- Respiratory
Medicare is offered to clients and four apart. Which part covers hospitalization?
Medicare part A
A client with anemia is receiving packed red blood cells. Which nursing action is important when administering the transfusion?
Monitoring the client response particularly within the first 10 minutes
Infants rarely receive more than 1 mL of digoxin or anything
More than 1 mL of anything is a big red flag!
Opioid antagonist
Naloxone
H&H 14/ 45%, plt 50,000, PT 5 sec
Normal, low, low
In the PACU, a client becomes of restless, tachycardic, and hypotensive. What should you do first?
Notify the provider This could be an indication of internal hemorrhage a the client may have to go back to surgery
universal donor
O negative
When is passing the laboratory work of a 65-year-old client scheduled for surgery The nurse understands which laboratory value may result in the cancellation of surgery?
Potassium 2.7
Which four defects are involved in tetralogy of fallot?
Pulmonic stenosis Right ventricle hypertrophy Overriding aorta Ventricular septal defect
A client is receiving a unit of packed red blood cells. Which findings would lead the nurse to suspect transfusion reaction caused by incompatible blood?
Respiratory distress Chills Backache
Ten minutes after the initiation of a blood transfusion the client reports chills and flank pain. Which nursing action would be preformed first?
Stop the infusion
During a transfusion a client develops chills and a headache. What is the priority nursing intervention?
Stop the transfusion
Which intervention is the priority when a nurse notices a client receiving a blood transfusion is having a hemolytic reaction?
Stop the transfusion immediately
The RN is reviewing the pre operative check list. The consent form has been signed. Who carries their responsibility to tell the client about the surgery, including the risk, Benefits, expected outcomes, and Alternatives?
Surgical doctor
T cell lymphocytes attack the host
TA-GVHD
Why is it important for nurses to be minimally familiar with the business side of healthcare?
To be a patient advocate To assist in the overall plan of care for clients
You don't look at this in a nurse to apply a thrombolytic device (Ted hose) and Subquential compression device (SCD). What is the purpose of each device?
To prevent thrombus and emboli
Only saline 0.9 is compatible with blood
True
The current treatment of children with Kawasaki disease includes high dose intravenous immunoglobulin (IVIG) along with salicylate therapy
True
When giving a diuretic elixir, it is okay to mix it with fruit juice to disguise the bitter taste and to prevent intestinal irritation from a concentrated solution
True
A can donate to AB
True.
Which client with anemia who is on blood transfusion therapy would require immediate intervention?
Wheezing
Supplies for blood transfusion
Y tubing Gloves
Common signs of digoxin toxicity in children.
nausea, vomiting, anorexia, bradycardia, dysrhythmias
