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MED-SURGE > EXAM 5--MEDSURGE > Flashcards

EXAM 5--MEDSURGE Flashcards

1
Q

most common type of blood product for transfusion

A

packed RBCs

PRBCs

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2
Q

PRBCs are used to increase the ____-____ capacity of blood

A

oxygen-carrying

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3
Q

PRBCs help the body get rid of?

A

carbon dioxide and other waste products

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4
Q

1 unit of PRBCs = raises hematocrit by?

A

2-3%

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5
Q

carry O2

A

RBCs

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6
Q

what is given in transfusions?

A

plasma
platelets
packed RBCs

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7
Q

liquid component of blood

A

plasma

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8
Q

plasma has proteins called?

A

clotting factors

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9
Q

expands blood volume and provides clotting factors

contains no RBCs

A

fresh frozen plasma (FFP)

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10
Q

1 unit of FFP= increases level of any clotting factor by ?

A

2-3 %

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11
Q

platelets aka

A

thrombocytes

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12
Q

tiny cell structures necessary in blood clotting process

A

platelets

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13
Q

platelets are needed in pts with?

A

bleeding disorders or

platelet deficiency

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14
Q

1 unit of platelets increases the average adult client’s platelet count by about ?

A

5,000 platelets/microliter

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15
Q

steps for initiating blood transfusion:

A

receive MD order
type and cross match
written consents and teaching
large-bore IV access

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16
Q

absolute 1st step in transfusion process

A

receive MD order

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17
Q

is done by the lab but will need to be confirmed by the nurse

A

type and cross match

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18
Q

which gauge IV is recommended for blood transfusions?

A

20 gauge or larger

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19
Q

equipment needed for blood transfusions

A 
IV pump
Y-filter IV tubing
NS
vital sign equipment
large bore IV
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20
Q

what are they looking for when typing and cross matching?

A

blood type & antibodies

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21
Q

when to do VS in transfusion process?

A

before, during, & after

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22
Q

stay with patient for first ___ min of transfusion

A

15 minutes

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23
Q

how many people need to be a part of blood transfusion?

A

2 licensed personnel

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24
Q

slow infusion rate and within ___ min of getting blood

A

30

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25
Q

inquire about history of previous?

A

blood product transfusions

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26
Q

what to check for in cardiovascular assessment

A

JVD & edema

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27
Q

what to check for in respiratory assessment

A

auscultation & use of accessory muscles

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28
Q

what to check for in integumentary assessment

A

rashes
petechiae
ecchymoses

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29
Q

what do look for in the sclera?

A

icterus

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30
Q

jaundice in sclera is indicative of ?

A

liver failure

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31
Q

worry about what in integumentary system?

A

current bleeding

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32
Q

3 checks with LPN for blood label

A

contents
expiration date
pt. info

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33
Q

transfusion must be complete within ?

A

4 hours

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34
Q

change tubing after every?

A

2 units

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35
Q

how fast to infuse FFP?

A

infuse over 30-60 minutes

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36
Q

infuse as fast as patient can tolerate

A

platelets

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37
Q

if FFP is not given what are they at risk for?

A

thrombolytic event & hemorrhage

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38
Q

adverse reactions to blood components

A 
restlessness
hives
N/V
torso, back, flank pain
dyspnea
flushing
hematuria
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39
Q

how fast to adverse reactions show up?

A

almost immediately (1st 15 minutes)

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40
Q

bloody urine

A

hematuria

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41
Q

lack of O2 in the blood stream can lead to which AE?

A

restlessness

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42
Q

a result of the vasodilating adverse reaction

A

flushing

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43
Q

what happens when RBCs aren’t compatable

A

clump together and sickle.

scrape inside of capillaries and excoriates vasculature

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44
Q

most common type of reaction

A

febrile non-hemolytic reaction

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45
Q

febrile non hemolytic reaction occurs mostly in patients with ?

A

previous transfusions

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46
Q

is febrile non hemolytic reaction life threatening ?

A

NO

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47
Q

Febrile non hemolytic reaction symptoms?

A

chills & fever 1 degree celsius elevation within 2 hours

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48
Q

most dangerous reaction

A

acute hemolytic reaction

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49
Q

acute hemolytic reaction can occur when?

A

immediately within 10 ml infused

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50
Q

sx of acute hemolytic reaction

A 
fever
chills
low back pain
nausea
chest tightness
dyspnea
anxiety
hemoglobinuria
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51
Q

occurs because of destruction of erythrocytes releasing hemoglobin from the cells where it is excreted by the kidneys

A

hemoglobinuria

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52
Q

how to prevent acute hemolytic reactions?

A

careful type & screening of pt & blood

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53
Q

what to do if patient has acute hemolytic reaction

A

STOP & discontinue TRANSFUSION
start rapid admin of NS
get VS
call physician

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54
Q

cause of allergic reaction to blood

A

sensitivity to plasma proteins

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55
Q

symptoms of allergic reactions of blood

A

urticaria
itching
flushing

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56
Q

if pt. responds to antihistamines…

A

they can resume transfusion

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57
Q

pre treat with what before blood transfusions?

A

antihistamines or corticosteroids

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58
Q

patient begint to have JVD, crackles in bilateral lung bases, dyspnea, & sudden anxiety.

what is going on with the patient?

A

FE overload

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59
Q

should you stop the infusion?

A

YES

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60
Q

when does transfusion related acute lung injury (TRALI) occur?

A

2-6 hours of transfusion

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61
Q

sx of TRALI

A 
acute SOB
hypoxia
hypotension
fever
pulmonary edema
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62
Q

TRALI is more likely occurs with which types of transfusions?

A

plasma & platelets

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63
Q

why is TRALI more likely with plasma & platelets?

A

bc they don’t go through as much screening

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64
Q

pulmonary edema sx

A

crackles
SOB
JVD

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65
Q

delayed hemolytic reaction occurs within?

A

14 days after transfusion

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66
Q

sx of delayed hemolytic reaction

A

fever
anemia
increased bilirubin level
jaundice

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67
Q

management of reactions

A 
stop the transfusion
maintain the IV with NS
assess the pt.
notify the MD
notify the blood bank
send blood bag and tubing to blood bank
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68
Q

a client has an order to receive 2 units of PRBCs for post op bleeding. during the transfusion of the first unit, the client complains of chills. List the actions in the sequence which the nurse should perform them.

A 
stop the infusion
notify the charge nurse
start a NS infusion
take the clients VS
send the blood bag to the blood bank
69
Q

a client with esophageal varies is admitted with hematemesis, and 2 units of blood are ordered. halfway through the first unit of blood the client complains of flank pain. the nurses first action should be to:

A

STOP the transfusion

70
Q

a client demonstrates signs and symptoms of a transfusion reaction. the nurse immediately stops the transfusion and next:

A

hangs a bag of NS with new tubing

71
Q

4 types of hypersensitivites

A

type 1 anaphylactic hypersensitivity
type 2 cytotoxic hypersensitivity
type 3 immune complex
type 4 delayed type

72
Q

affects multiple organs and can have mild to severe reactions IgE mediated!

A

anaphylactic

73
Q

the faster the onset of anaphylaxis– the ?

A

more severe the reaction

74
Q

mild anaphylaxis

A 
peripheral tingling
warmth
nasal congestion
periorbital swelling
pruirits
sneezing watery eyes
75
Q

moderate anaphylaxis

A

flushing
warmth
anxiety
itching

76
Q

abrupt onset

A

severe anaphylaxis

77
Q

sx of severe anaphylaxis

A 
bronchospasms
laryngeal edema
SOB
cyanosis
hypotension
78
Q

prevention of anaphylaxis

A

avoid the allergen

79
Q

pts should carry around what?

A

auto-injection system for epinephrine

80
Q

common causes of allergic rhinitis

A

hay fever
seasonal allergies
IgE mediated

81
Q

allergic rhinitis is the most common form of ?

A

respiratory allergy.

82
Q

when does allergic rhinitis begin?

A

ingestion or inhaling the antigen

83
Q

is the major mediator of allergic reactions

A

histamine

84
Q

sx of allergic rhinitis

A

sneezing
watery eyes and nasal passages
itching

85
Q

type of therapy for allergic rhinitis

A

avoidance therapy
pharmacologic therapy
immunotherapy

86
Q

skin rashes associated with certain medications

A

drug reactions

87
Q

appear suddenly, have a vivid color, more intense reactions and disappear rapidly after the medication is withdrawn

A

drug reactions

88
Q

what to tell pts with drug reactions

A

stop taking the med immediately and notify the physician

89
Q

IgE mediated except for a newly identified ____ mediated food allergies

A

T-cell

90
Q

what are the most severe food allergies?

A

peanuts and tree nuts

91
Q

symptoms of food allergies

A

classic allergic symptoms and GI upset

92
Q

common symptoms of latex allergies

A

rhinitis
conjuctivitis
asthma
anaphylaxis

93
Q

an autoimmune disorder affecting the myonureal junction

A

myasthenia gravis

94
Q

what is myasthenia graves characterized by?

A

varying degrees of weakness of the voluntary muscles

95
Q

80% of MS patients present with?

A

diplopia and ptosis

96
Q

weakness of the face and throat muscles results in ?

A

bland facial expression, impaired voice & dysphagia

97
Q

impaired voice

A

dysphonia

98
Q

what are MS patients at risk for?

A

aspiration

99
Q

an autoimmune attack on the peripheral nerve myelin

A

guillian-barre syndrome

100
Q

guillian-barre syndrome results in ?

A

ascending weakness
dyskinesia
hyporeflexia
paresthesia

101
Q

guillian barre starts with muscle weakness an diminished reflexes and may progress to ?

A

tetraplegia

102
Q

should be especially concerned with what in guillian barre ?

A

neuromuscular respiratory failure

103
Q

an inflammatory, autoimmune disorder that affects nearly EVERY ORGAN in the body

A

systemic lupus erythematosus

104
Q

begins because of an immune system dysfunction where the immune system inaccurately recognizes one or more of the cell’s nucleus as foreign, seeing it as an antigen

A

lupus

105
Q

a classic identifiable characteristic of lupus is?

A

butterfly rash!

106
Q

acute or chronic skin inflammation

results from direct skin contact with chemical or allergen

A

contact dermatitis

107
Q

sx of contact dermatitis

A 
itching
burning
erythema
skin lesions
edema
followed by:
weeping
crusting
and drying and peeling of the skin

if severe:
hemorrhagic bullae may appear

108
Q

understand that latex allergies are classified as?

A

abrupt, life-threatening

109
Q

delayed type of latex allergy results in a ?

A

contact dermatitis reaction

110
Q

assume that all patients are infected with?

A

microorganisms

111
Q

airborne precautions

A

neg air pressure in room.

must wear N95 fitted respirator

112
Q

droplet precautions

A

3-6 feet of a patient you must wear a mask

113
Q

contact precautions

A

gowns and gloves

disposable stethescope and tools

114
Q

how does contact spread?

A

skin to skin

115
Q

positive blood cultures indicating bacteremia is an indicative of ?

A

sepsis

116
Q

early signs of acute organ dysfunction:

A 
systolic BP over 90
RR over 20
decreased renal output
elevated liver function tests
change in LOC
117
Q

1st line of defense

A

skin
digestive tract
respiratory tract

118
Q

act as filters to remove debris and antigens entering the respiratory tract

A

tonsils and adenoids

119
Q

act as filters to remove debris and antigens and to foster contact with T lymphocytes

A

lymph nodes

120
Q

contains stem cells for B lymphocytes, which mature and become antibody-producing plasma cells that react to many bacteria, viruses and other antigens; controls humoral immunity

A

bone marrow

121
Q

contains cells that mature into T lymphocytes and specifically react to viruses, parasites, fungi, foreign tissue, and other antigens; controls cell-mediated immunity

A

thymus

122
Q

act as a filter to remove debris and antigens and to foster contact with T lymphocytes

A

spleen & lymph nodes

123
Q

The antibodies (large proteins) that defend against foreign invaders. Induces the clumping effect of specific antigens (agglutination) to clear them from the body.`

A

immunoglobulins

124
Q

enhances phagocytosis and crosses the placenta, blood borne and tissue infections (75%) (Remember –Greatest)

A

IgG

125
Q

passed to neonate in breast milk and prevents absorption of antigens from food, appears in body fluids, protects against respiratory, GU and GI infections (15%) (Remember: A is first letter of alphabet, first-line of defense for babies)

A

IgA

126
Q

activates the complement system and appears as the first produced in response to bacterial and viral infections (10%)

A

IgM

127
Q

Role is unkown

A

IgD

128
Q

combats parasitic infections, takes part in allergic and some hypersensitivity reactions. (0.004%) (Remember: IgE=Epi)

A

IgE

129
Q

humoral immunity

produce antibodies or immunoglobulins

A

B lymphocytes

130
Q

cellular immunity

Attack invaders directly, secrete cytokines, and stimulate immune system responses

Helper T cells

Cytotoxic T cells

Memory cells

Suppressor T cells (suppress immune response)

A

T lymphocytes

131
Q

Destroy antigen coated with antibody

A

null cells

132
Q

Defend against microorganisms and some malignant cells

A

natural killer cells

133
Q

Circulating plasma proteins made in the liver and activated when antibody connects to antigen playing an important defense against microbes

A

complement system

134
Q

complement system is activated by 3 pathways:

A

classic
lectin
alternative

135
Q

Affects the host via direct or indirect effects on one or more components of the immunoregulatory network; help to enhance the immune system

A

immunomodulators

136
Q

3 types of immunomodulators

A

interferons
colony stimulating factors
monoclonal antibodies

137
Q

antiviral and antitumor properties used to treat multiple sclerosis and chronic hepatitis

A

interferons

138
Q

play a key regulatory role in the growth and differentiation of bone marrow cells.

A

colony-stimulating factors

139
Q

growth and production of targeted antibodies for specific pathologic organisms

A

Monoclonal antibodies:

140
Q

assessing the cardiovascular system

A 
pericardial effusin
anemia
HR
BP
vasculitis
141
Q

assessing the GI system

A

N/V/D
Colitis
splenomegaly

142
Q

myths about HIV

A

can be transmitted by casual contact.

an immediate death sentence

is only a gay male disease

means a person has AIDS

can be transmitted by mosquitos

143
Q

what is HIV

A

human immunodeficiency virus

144
Q

HIV is the virus that causes?

A

AIDS

145
Q

attacks the CD4 T-cells which are some of the primary cells that allow our bodies to fight off infections

A

HIV

146
Q

lacking resistance to disease

A

immunodeficiency

147
Q

a sub-microscopic parasite that invades living cells for replication.

A

virus

148
Q

how is HIV transmitted?

A

contact with sexual transmitted fluids

contact with infected blood

children born from HIV infected mothers

149
Q

which fluids for HIV?

A

semen and vaginal secretions

150
Q

how contact with infected blood?

A

sharing needles, breaks in skin causing blood to blood contact

151
Q

how is HIV transmitted from mother to child

A

amniotic fluid and breast milk

152
Q

how is HIV NOT transmitted

A

casual contact
food preparation
biting
insects

153
Q

initial onset of HIV transmission

A

flu-like symtopms

154
Q

Viral load is Extremely High—Body is developing antibodies and continues to build antibodies for the 1st

A

2-4 weeks of the virus

155
Q

Primary test such as ? may not detect a virus in the early stages BECAUSE THERE ARE NOT ENOUGH ANTIBODIES BUILT UP IN THE BODY YET, resulting in a False (-).

A

EIA & ELISA

156
Q

these 2 tests do not test for specific ?

A

antibodies

157
Q

what to the 2 tests test for?

A

presence of B cells.

158
Q

it could take up to ___ weeks for enough detectable antibodies to build up

A

36

159
Q

Client returns to the hospital years later due to illness, ELISA is performed again and Antibodies are THROUGH THE ROOF!!

A

secondary infection

160
Q

ELISA lead to ___ __ for confirmation of HIV

A

western blot

161
Q

___ markers are then tested

A

CD4

162
Q

May test negative on the HIV antibody test

Client is MOST infectious during the initial phase of this stage (Extremely high Viral Load)

Equalization occurs but CD-4 count is lower.

A

stage 1–primary infection

163
Q

in stage 2 CD4 count falls between __ and then below ___ at which point the client is considered to have AIDS

A

499-200

then below 200

164
Q

Fungal Infection (oral) occurs in most every AIDS client

A

candidiasis

165
Q

involuntary weight loss

A

wasting syndrome

166
Q

stage 2 most common symptoms

A

kaposi’s sarcoma
candidiasis
wasting syndrome

167
Q

no vaccine or cure due to

A

mutation of the virus

168
Q

how to protect yourself from HIV/AIDS

A 
universal precautions
abstinence
monogamy
safer sex
use care with alcohol and drug use

MED-SURGE (5 decks)

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