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NF3 > Midterm > Flashcards

Midterm Flashcards

1
Q 
A patient with cerebral edema would most likely be order what type of solution?
A. 3% Saline
B. 0.9% Normal Saline
C. Lactated Ringer’s
D. 0.225% Normal Saline
A

A. 3% Saline. A patient with cerebral edema would be ordered a HYPERTONIC solution to decrease brain swelling. The solution would remove water from the brain cells back into the intravascular system to be excreted. 3% Saline is the only hypertonic option.

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2
Q

_______ solutions cause cell dehydration and help increase fluid in the extracellular space.

A

Hypertonic

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3
Q

T or F - D5W solutions are sometimes considered a hypotonic solution as well as an isotonic solution because after the body metabolizes the dextrose the solution acts as a hypotonic solution.

A

TRUE. D5W is classified as a ISOTONIC fluid BUT after adminstration the body metabolizes the dextrose and the fluid left over is a hypotonic solution.

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4
Q

Which patient below would NOT be a candidate for a hypotonic solution?
A. Patient with increased intracranial pressure
B. Patient with Diabetic Ketoacidosis
C. Patient experiencing Hyperosmolar Hyperglycemia
D. All of the options are correct

A

A: Patient with increased intracranial pressure

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5
Q 
Which condition below could lead to cell lysis, if not properly monitored?
A. Isotonicity
B. Hypertonicity
C. Hypotonicity 
D. None of the options are correct
A

Hypotonicity

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6
Q

Nursing management of fluid volume deficit.
Monitor?
Cardiac system related, resp. system related, lab values, other assessments

A

Monitor: Intake and output, Daily weights, Check for skin breakdown and good oral care
Lab Values: Electrolytes, CBC, urine specific gravity
Cardiovascular: Assess for Hypotension and weak pulses
Respiratory: assess respiratory system and tissue perfusion
Assess: Check orientation, vision, hearing, reflexes, muscle strength

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7
Q

what are the Neurological and Respiratory Signs of fluid volume Excess to watch for?

A 
Neurological
o	Changes in LOC
o	Confusion
o	Headache
o	Seizures
Respiratory
o	Pulmonary congestion
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8
Q

what are the Cardiovascular and Gastrointestinal Signs of fluid volume Excess to watch for? and type of edema

A 
Cardiovascular
o	Bounding pulse
o	Increased BP and JVD
o	Presence of S3
o	Tachycardia
Gastrointestinal
o	Anorerxia 
o	Nausea 
Edema
o	Dependent pitting edema
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9
Q

With fluid volume excess, what will the hematocrit look like?

A

The hematocrit will be reduced from the dilution of excess water

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10
Q

Hypovolemic shock happens when a

A

a sudden and significant loss of blood or body fluids drops your blood volume.

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11
Q

what are the Treatment goals for Hypovolemic shock

A

fluid resuscitation, correct underlying cause that is leading to the fluid loss….example: hemorrhaging: surgery (get the patient ready for surgery).

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12
Q 
Hemorrhage, Plasma loss through burns
Decreased body fluids
GI loss – bleeding, vomiting, diarrhea
Diabetes insipidus
Diuresis (increased or excessive production of urine.)
Can all Cause what?
A

Hypovolemic Shock

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13
Q

S/S to watch for in Hypovolemic shock

A 
o	Increased systemic vascular resistance
o	Poor skin turgor
o	Thirst
o	Oliguria (decrease urine output)
o	Low systemic and pulmonary preloads
o	Rapid heart rates
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14
Q

Define transfusion

A

infusing blood or blood products in order to replace blood cells and clotting factors
o IV infusion of whole blood or blood components
o Most commonly a homologous (allogenic) transfusion

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15
Q

Define type and screen.

How long is it valid for?*

A

Blood is tested to determine blood (ABO) group, Rh factor and presence of major antibodies.
Valid for 96 hours (4days) from the time of collection

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16
Q

Define cross-match

A

Blood from donor & recipient are mixed in the lab, and incubated about 1 hour to check for any reactions

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17
Q

what is Autologous Blood Transfusion

A

Can donate one to five units of own blood pre-operatively
 Can be done up to 5 weeks before planned surgery
 Blood can be recovered from drains during or immediately following a surgery (perioperative salvage)
 Decreased risk of complications

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18
Q

what does whole blood contain

A

Contains RBC, WBC, platelets, plasma, cryoprecipitate
 Not routinely used:
o Used when blood bank has to get emergency donors due to inadequate blood supply in the bank
o Autologous blood is in the form of whole blood
 Approx 500 ml/unit

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19
Q

*Blood transfusions have to be done within how many hours and start within…

A

within 4 hours, and start within 1 hour

20
Q

What kind of allergic reactions will you see with blood transfusions

A 
Allergic Reactions You Will See 
•	Hives
•	Flushed skin 
•	LOWER BACK  - AFFECTS YOUR KIDNEYS 
•	Fever 
o	STOP IMMEDIATELY
21
Q

what is the LPNs role in administering blood

A 
•	Hanging the blood 
•	Can do the checks with another nurse 
•	Assessments include 
o	Patency of the line 
o	Site
o	V/S - MONITOR EVERY 15 MINUTES Q1H, THAN 30 MINUTES Q1H, THAN 1 HOUR FOR Q2H 
o	SPO2
o	CAN STOP THE TRANSFUSION IF YOU NOTICE ALLERGIC REACTION  - USUALLY OCCUR WITHIN THE FIRST 5 MINUTES
22
Q

Blood replacement or transfusion, or blood component therapy, is the IV admin of whole blood, or a component.
What does whole blood contain?

A

RBC, WBC, Platelets, Plasma, Cryoprecipitate

Not routinely used
o Used when blood bank has to get emergency donors blood products quickly
o When there is an inadequate blood supply in the bank
o Autologous blood is in the form of whole blood

23
Q

why are Packed RBC’s usually administered?

A

Used to Increase oxygen carrying of blood in anemias, post-surgery, and disorders with slow bleeding where hemoglobin levels are consistently dropping
- hemorrhage, surgery, trauma

24
Q

*You do not transfuse whole blood unless hemoglobin is less than…?
What is the shelf life?

A

70

42 days

25
Q

When do you need to begin transfusion of RBCs after receipt of blood?
How long do you have to transfuse over?

A
  • Begin transfusion within 1 hour of receipt of blood

- Transfuse in under 4 hours

26
Q

Platelets are made from whole blood and are used when?
Shelf life of ?
Must be used within?

A

for bleeding due to decreased platelet production or abnormal platelets. May be used prophylactically for invasive procedures when platelet levels are low.

  • shelf life of 5 days
  • used within 4 hours of hanging
27
Q

Plasma is used for what reason?

A

used to replace clotting factors; reverses the effects of warfarin and heparin.

28
Q

If a patient is taking warfarin or heparin what lab value levels can be unsafely high and what should be administered?

A

their INR and PTT levels - we can administer plasma to bring down those levels and help blood to clot more effectively

29
Q

Plasma - usually referred to as FFP/FP by orders - what is the shelf life of fresh frozen plasma?

A

1 year

30
Q

If you look at pt with peripheral pitting edema/weeping edema, what would you notice to be low in their blood work and why is it causing edema?

A

albumin levels are low - not enough albumin/protein in blood stream to hold the fluid in bloodstream

31
Q

what is the only solution you can administer with blood products?

A

Normal saline

no medication while transfusion
need an infusion pump to administer blood products

32
Q

what are 5 examples of side effects with blood transfusions that should be reported immediately

A
  • Fever
  • Shortness of Breath
  • Itching
  • Chills
  • General feeling unwell
33
Q

Adverse reactions to blood transfusions are most likely to occur in the first 5-15 minutes, so you run transfussion at __mL/min then increase.
If adverse reaction occurs what do you do?

A

1-2mL/min
• Immediately stop transfusion and report to physician
• Do NOT FLUSH line

34
Q

what are three emergency medications administered for adverse reactions in blood transfusion?

A

Epinephrine
Diphenhydramine (Benadryl)
Hydrocortisone
• Must have an order to administer

35
Q

During transfusion of blood, how often are vitals taken?

A

Vitals are to be done the 1st 15 minutes, than q1h (MINIMUM) until infusion is complete
(Infusion must be completed within 4 hours of starting)

36
Q

Blood tubes are discarded after

A

8 hours

The same blood tubes can be used for different blood products

37
Q

Transfusion Reactions – Nursing Actions

A 
• Stop the transfusion immediately
• Provide emergency care for ABC’s
• DO NOT flush the IV line
• Change IV set and start normal saline
•	Notify physician:
	Provide medications as ordered
	Blood work drawn & urine collected as ordered
• Report to transfusion medicine, return unused blood & tubing
• Document reaction and event
38
Q 
A patient is admitted to the hospital with a history of vomiting for 2 days and diminished oral intake. Arterial blood gas measurements on admission are as follows: pH, 7.30; arterial partial pressure of carbon dioxide (PaCO2), 36 mm Hg; arterial partial pressure of oxygen (PaO2), 92 mm Hg; bicarbonate level (HCO3–),18 mmol/L. The nurse understands that the patient’s acid–base imbalance is which of the following?
 Metabolic acidosis.
 Metabolic alkalosis.
 Respiratory acidosis.
 Respiratory alkalosis.
A

A. Metabolic acidosis.
A pH of less than 7.35 and a normal PaCO2, along with a HCO3– level of less than 22 mmol/L and a normal PaO2, are indicative of metabolic acidosis. Metabolic acidosis can result from dehydration, including that caused by vomiting.

39
Q

. The following are indications for insertion of nasogastric tube except:

a. Post-operative healing
b. Diagnosis
c. Ambulation
d. Feeding

A

ambulation

40
Q

Which is the most accurate way to confirm an NG tube placement?

a. Palpate the stomach
b. X ray
c. Flush with sterile water

A

x-ray

41
Q

Name at least 3 purposes of Suctioning?

A

• Enteral feeding
• Gastric decompression
• Relieve abdominal distension caused by:
o complications of surgery (paralytic ileus)
o acute upper GI bleed
o intestinal obstruction
• Prevent nausea and vomiting
• Lavage or wash the stomach
• Obtain contents of stomach for diagnostic testing

42
Q

What is the Procedure for Suctioning?

A
  • DO NOT suction for > 10 – 15 seconds
  • Allow 30-60 seconds between suctioning passes
  • Suction a maximum of 3 times per episode
  • DO NOT force the catheter
  • If using O2 – remove for as short a time as possible
43
Q

Which lab value helps determine nasogastric loss?

A

pH

44
Q

what is the Calculation for fluid loss

A

Total ng loss (output)/time(hours) = mls/hour

45
Q

• Name at least 5 IV Therapy COMPLICATIONS

A
  • INFECTION
  • INFILTRATION or INTERSTITIAL FLUID OVERLOAD
  • Extravasation
  • Phlebitis
  • Air Emboli
46
Q

● What are the signs and symptoms of a deep vein thrombosis (DVT)? List at least four.

A 
●	Spasm
●	leg pain,
●	numbness,
●	redness, itching,
●	rash,
●	shortness of breath, and.
●	ulceration of the skin.

NF3 (10 decks)

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