PPNC2 Exam 1 Module 1
transfusion-associated circulatory overload reaction
related to volume overload; pts. 70+ and infants at highest risk; usually occurs within 6 hours
chills, fever, low back pain
Acute-intravascular hemolytic reaction signs and symptoms
A, C, D, E
Choose the procedures that are classified as aseptic techniques. SATA. a. Handwashing b. CVL change c. Emptying a full foley drainage bag d. Wiping bedside prior to preparing a sterile field e. Cleaning IV ports before med admin
febrile, nonhemolytic reaction
Most common blood transfusion reaction; caused by WBC antigen-antibody reactoin; beginning in early to late transfusion to after completion
B
The nurse is inserting a Foley catheter for an elderly client with benign prostatic hypertrophy (BPH). The technique for this procedure is classified as ...? a. Aseptic b. Sterile
C
The nurse is preparing a blood transfusion set. Which solution should be used to prime the tubing? a. 0.45% sodium chloride (1/2NS) b. Dextrose 5% in 0.45% sodium chloride (D5 1/2 NS) c. 0.9% sodium chloride (normal saline) d. Dextrose 5% in 0.9% sodium chloride (D5NS)
A
What type of restraint order would this patient fall under? A male patient is admitted with an elevated blood alcohol level. He is admitted to your unit with IV therapy running. He attempts to pull out his line. When you try to redirect him, he verbally threatens you and tries to kick you away from his bed with a purposeful aim. a. Behavioral b. Medical
use autologous blood or blood that's IgA deficient
anaphylactic and severe allergic reaction prevention
anxiety, urticaria, dyspnea wheezing
anaphylactic and severe allergic reaction signs and symptoms
2 RNs
at least _______________ should check blood products
anaphylactic and severe allergic reaction
caused by recipient allergy to a donor agent (IgA); agglutination of RBCs obstructing capillaries and blocking blood flow, causing s/s to all major organ systems; occurs within minutes
antipyretics (acetaminophen)
febrile, nonhemolytic prevention/pretreatment
sudden shaking, chills (rigors), fever, headache, and vomiting
febrile, nonhemolytic reaction signs and symptoms
Acute-intravascular hemolytic reaction
incompatibility of ABO red blood cells in the blood; usually caused by misidentification or improper labeling within minutes of initating.
4
the infusion rate should not go beyond how many hours?
B
the nurse is changing the soiled bed linens of a client with a wound that is draining serosanguinous exudate. Which PPE would the nurse wear? a. mask b. clean gloves c. sterile gloves d. shoe covers
A
the nurse is preparing to change a client's dressing. For which reason would the nurse use surgical asepsis? a. keeps the area free of microorganisms b. confines microorganisms to the original site c. protects self from microorganisms in the wound d. reduces the risk for growing opportunistic microorganiss
dyspnea, cough, crackles, rales, distended neck veins
transfusion associated circulatory overload reaction signs and symptoms
don't restart unless ordered, administer antipyretic
what should you do if a febrile, non-hemolytic reaction occurs?
high-fowler position, diuretic, chest x-ray, slow rate
what should you do if a transfusion-associated circulatory overload reaction occurs?
stop the transfusion and never restart (get help, change administration set, administer NS at a rate to maintain IV access, treat shock and alert HCP)
what should you do if an acute-intravacular hemolytic reaction occurs?
stop, epinephrine, never restart, maintain IV access
what should you do if an anaphylactic and severe reaction occur?
B
which action should the nurse take to maintain sterility when performing a dressing change? a. put unopened sterile glove package carefully on the sterile field b. remove the sterile drape from its package by lifting it by the corners c. don sterile gloves before opening the package containing the field drape d. pour irrigation liquid from a height of at least 3 inches above the sterile container
A
which nursing action would be performed first in a client who reports chills and flank pain 10 minutes after the initiation of a blood transfusion? a. stop the transfusion b. obtain the vital signs c. notify HCP d. maintain the flow of NS
A, D, E
which nursing intervention is necessary before a blood transfusion is administered? SATA. a. obtain client's vitals b. monitor hemoglobin and hematocrit c. allow blood to reach room temp d. determine typing and crossmatching of blood e. use a Y-type infusion set to initiate 0.9% NS
B
which technique would the nurse use in attempting to glove the second hand when donning sterile gloves? a. grasp the finger portion of the second glove and lift; then insert remaining hand into glove b. insert gloved fingers under cuff of second glove and lift glove; then slide ungloved hand into glove c. using your gloved hand, grasp the folded edge of the second glove with two fingers and place glove on nondominant hand d. don glove on nondominant hand first, then hold the glove away from body below waist to slide glove on
A
which technique would the nurse use to maintain surgical asepsis? a. change the sterile field after sterile water is spilled on it b. put on sterile gloves before opening a container of sterile saline c. place a sterile dressing no more than half an inch from the edge of the sterile field d. clean the surgical area with a circular motion, moving from the outer edge toward the center
B
which type of asepsis if the nurse using when he or she washes his or her hands before changing a client's postoperative dressing? a. wound asepsis b. medical asepsis c. surgical asepsis d. concurrent asepsis
C
while receiving a blood transfusion, a client develops flank pain, chills, and a fever. Which type of transfusion reaction would the nurse conclude that the client is experiencing? a. allergic b. pyrogenic c. hemolytic d. anaphylactic
NS
you can only add ________ with a blood transfusion, no meds or other fluids b/c will rupture RBC
30
you need to start the transfusion within how many minutes since retrieving from a blood bank?