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Med Surg 1 > Week 1 > Flashcards

Week 1 Flashcards

1
Q

platelet transfusion

A

does not need to match blood type

idicated for platelets <20k
200 to 300 ml. (15/30min total)

small filter, short tubing

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2
Q

plasma transfusions

A

match ABO blood type
frozen upon transfusion

infuse 200 ml FFP over 30-60 min

Y-set or straight filtered tubing

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3
Q

WBC transfusion

A

risk for severe reaction

400ml over 45 to 60 min provider presence

**amhotericin b *

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4
Q

amphotericin b antibiotics & wbc transfusion

A

wait 4-6hrs for admin – will hemolyze wbc

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5
Q

what to do in acute hemolytic transfusion reaction

A

result of incompatible blood

  1. stop infusion
  2. assess
  3. initiate 0.9% NaCl w new tubing
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6
Q

signs & symptoms of acute hemolytic transfusion reaction

A

fever
chills
lower back pain
dark urine
tachycardia / tachypnea
flushing
hypotension
chest pain
nausea
anxiety
impending doom

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7
Q

circulatory overload occurs when & nursing actions

A

transfusion rate is too fast

  1. slow transfusion
  2. elevate head of bed & postion client upright w feet lower than heart
  3. admin meds (*diuretic but check K+ first)
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8
Q

s/s of circulatory overload

A

SOB
hypertension
crackles
cough
dyspnea
jugular vein distention
tachycardia

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9
Q

in the first 15-30 minutes of a blood transfusion, a nurse must

A

stay with the client and assess vitals every 15 min

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10
Q

before blood transfusion a nurse must (7):

A
  1. assess lab values & verify order/consent
  2. verify type & crossmatch
  3. initiate large bore IV access
  4. explain reason for transfusion
  5. Inspect blood product
  6. prime w/ 0.9% NaCl
  7. verify client & compatibility w 2 RN’s
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11
Q

in an autologous transfusion

A

client’s can donate their own blood 6 weeks prior to surgery

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12
Q

salvage blood re-infusion

A

must occur within 6 hours of collection

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13
Q

BUN range

A

6 to 24 mg/dl

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14
Q

hematocrit ranges

A

women 36% to 48%
men 40% to 54%

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15
Q

s/s of hypovolemia

A

tachycardia / tachypnea
hypotension
hypothermia
**low-grade fever
decreased skin tugor
n/v/c

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16
Q

lab values indicating hypovolemia

A

*INCREASED values
Hct/Hgb
BUN
sodium
urine specific gravity
blood osmolality

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17
Q

4 nursing actions for hypovolemia

A
  1. monitor I&O
  2. vitals & loc
  3. weight - 8hrs
  4. gait & movement
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18
Q

4 nursing actions for hypovolemic shock

A
  1. administer O2
  2. vitals every 15 min
  3. fluid replacement
  4. vasoconstrictors / (+) inotropic meds
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19
Q

s/s of hypervolemia

A

tachycardia / tachypnea
hypertension
crackles
cough
weakness
cool skin
edema
distended neck veins (jugular)

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20
Q

lab values indicating hypervolemia

A

*DECREASED LABS
Hct / Hgb
BUN
urine specific gravity
blood osmolality

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21
Q

2.2 lbs / 1kg of weight loss = how much fluid loss

A

1L

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22
Q

2 nursing actions for hypervolemia

A
  1. monitor I & O
  2. assess breathing
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23
Q

3 nursing actions for pulmonary edema

A
  1. position client in high-fowler’s
  2. administer oxygen
  3. morphine, nitrates, & diuretics
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24
Q

calcium range

A

9.0 to 10.5

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25
Q

magnesium range

A

1.3 to 2.1

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26
Q

chloride range

A

98 to 106

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27
Q

phosphorus range

A

3.0 to 4.5

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28
Q

s/s of hyponatremia

A

hypotension
hypothermia
hyperactive bowel
tachycardia
confusion
muscle weakness/ twitching
edema

*relates to hypervolemia

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29
Q

lab values indicating hyponatremia

A

DECREASED
*sodium
*urine specific gravity
* blood osmolarity

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30
Q

replacement sodium should not exceed the rate of

A

12 mEq/L in 24 hours

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31
Q

saline solution for hyponatremia

A

lactated ringer
0.9% isotonic saline

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32
Q

s/s of hypernatremia

A

hyperthermia
thirst
hypotension
tachycardia
muscle weakness
dry mucous membranes

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33
Q

lab values for hypernatremia

A

*INCREASED
sodium
blood osmolality
urine specific gravity

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34
Q

potassium values

A

inverse w sodium
3.5 to 5

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35
Q

s/s of hypokalemia

A

*flat T-wave
hypotension
n/v/ constipation
HYPOactive bowel
shallow breathing
lethargy

increased risk for digoxin toxicity

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36
Q

potassium should be administered at a rate of

A

10 mEq/L

37
Q

s/s of hyperkalemia

A

*peak T-wave
hypotension
flaccid paralysis
diarrhea
HYPERactive bowel
oliguria

can cause metabolic acidosis
associated with diabetic keto-acidosis

38
Q

Meds for excretion when dealing w hyperkalemia

A

loop diuretics (furosemide)
sodium polystyrene sulfonate
albuterol (beta2 agonist)
patiomer

39
Q

s/s of hypocalcemia

A

HYPERactive bowel
diarrhea
abdominal cramps
parathesia of fingers/lips
low vitamin D
impaired clotting time
(+) chovstek (face twitch)
(+) trosseau’s (bp cuff & hand spasm)

40
Q

nursing considerations for hypocalcemia

A

Vitamin D supplements
seizure precautions
low stimulation

*calcium gluconate if severe

41
Q

s/s of hypomagnesemia

A

<1.3
constipation
HYPOactive bowel
paralytic ileus
(+) chovstek (face twitch)
(+) trosseau’s (bp cuff & arm)

42
Q

medication to reverse hypermagnesemia

A

calcium gluconate

43
Q

medication for hypomagnesemia

A

oral magnesium sulfate
(iv if severe)

44
Q

nursing interventions for hypokalemia

A

assess hand grasps for muscle weakness

assess deep tendon reflexes

45
Q

a nurse is caring for a client who has a nasogastric tube attached to low-intermittent suctioning. the nurse should monitor for which of the following electrolyte imbalances?

  1. hypercalcemia
  2. hyponatremia
  3. hyperphosphatemia
  4. hyperkalemia
A
  1. hyponatremia
46
Q

antidote for benzo’s (-pam/lam)

A

flumazenil

47
Q

8 nursing actions for malignant hyperthermia

A
  1. stop surgery
  2. protect airway = admin100% O2
  3. admin dantrolene (muscle relaxant)
  4. assess ABG’s (risk for hyperkalemia)
  5. infuse ice IV 0.9% NaCl
  6. apply cooling blanket
  7. insert indwelling catheter
  8. monitor
48
Q

s/s of malignant hyperthermia

A

extreme temp elevation
hypotension
tachycardia
muscle rigidity
myoglobinuria

49
Q

a nurse is caring for a client who reports a headache following an epidural regional nerve block. which of the following actions should the nurse take?

  1. decrease the client’s fluid intake
  2. apply pressure to the puncture site
  3. place the head of the bed flat
  4. instruct the client to lie prone
A
  1. place the head of the bed flat
50
Q

reversal agent for opiods

A

naloxone

51
Q

pre-op assessment includes (5)

A
  1. detailed history
  2. allergies
  3. anxiety level
  4. vitals & head to toe
  5. venous thromboembolism risk
52
Q

ati NPO rules for surgery

A

6hrs = solid food
2 hrs = clear liquid

53
Q

nursing considerations for prophylactic antibiotics

A
  1. have client void before taking them
  2. admin ONE HOUR before surgery
54
Q

4 pre-op nursing actions

A
  1. WITNESS informed consent
  2. chart last time client ate/drank
  3. admin heart meds b4 surgery
    *****beta-blockers
  4. apply anti-embolism stockings
55
Q

BMi range

A

18.5 to 24.9

56
Q

a nurse is caring for a client who manifests indications of hypovolemia while in the PACU. Which of the following findings requires actions by the nurse? sap

  1. urine output less than 25 mL/hr
  2. Hematocrit 53%
  3. BUN 24 mg/DL
  4. tenting of skin over the sternum
  5. apical pulse rate of 62/min
A
  1. urine output less than 25 mL/hr
  2. Hematocrit 53%
  3. BUN 24 mg/DL
  4. tenting of skin over the sternum
57
Q

a nurse is caring for a client who reports n/v 2 days post-op following a hysterectomy. Which of the following actions should the nurse perform first?

  1. assess bowel sounds
  2. administer an antimimetic med
  3. restart prescribed IV fluids
  4. Insert a prescribed NG tube
A
  1. assess bowel sounds
58
Q

priority in post- op

A

A - AIRWAY
B- BREATHING
C- CIRCULATION

59
Q

nursing actions for unresponsive post op patient

A

*lateral position (aspiration)
*no knee under the pillow (venous return)

60
Q

4 nursing actions for paralytic illeus

A
  1. monitor bowel function
  2. encourage ambulation
  3. admin METOCLOPROMIDE
  4. NG tube prn
61
Q

2 considerations for older adults w IV therapy

A
  1. blood pressure cuff instead of tourniquet
  2. hand below heart level
62
Q

Infiltration & 4 nursing actions

A

*cool skin, edema, swelling, & pallor

  1. stop infusion
  2. elevate & encourage ROM
  3. cold/warm compress
  4. check IV & restart
63
Q

a nurse is assessing the IV catheter insertion site & notes swelling at the site w/ decreased skin temp. which of the following actions should the nurse take? (sap)

  1. stop infusion
  2. start a new Iv access distal to the site
  3. apply warm compress to the insertion site
  4. elevate the client’s arm
  5. Obtain a specimen for culture at the insertion site
A
  1. stop infusion
  2. apply warm compress to the insertion site
  3. elevate the client’s arm
64
Q

platelet units should be administered within

A

15 to 30 min/unit

65
Q

fresh frozen plasma should be administered

A

30 to 60 min/unit
*elevated aPTT

66
Q

Whole blood

A

*transfused over 2 to 4 hours

acute blood loss, dehydration, & shock

66
Q

WBC should be administered within

A

45 min to 1 hour

67
Q

IV solution used with blood products

A

0.9% sodium chloride

68
Q

transfusions require ___ & must be completed within ___. while tubiing must be changed every ____

A

require 2 nurse verification

completed within 4 hours

changed every 2 units

69
Q

blood consideration for older adults

A

wait 2 hrs between transfusions of multiple units

70
Q

a nurse must document (7) things with blood

A
  1. blood product type
  2. blood bank # of product
  3. total volume infused
  4. time of start/finish
  5. vitals
  6. adverse effects
  7. extra actions taken
71
Q

packed RBS are administered for

A

anemia

72
Q

a nurse is transfusing packed RBC’s to a client w anemia. client reports a sudden headache & chills. client’s temp is 2 degrees higher than baseline. In addition to notifying the provider. which additional actions should the nurse take? sap

  1. stop the transfusion
  2. place the client in an upright position w feet down
  3. remove the blood bag and tubing from the iv catheter
  4. obtain a urine specimen
  5. infuse 5% dextrose in water through the IV
A
  1. stop the transfusion
  2. remove the blood bag and tubing from the iv catheter
  3. obtain a urine specimen
73
Q

a nurse is assessing a client through a transfusion of a unit of whole blood. the client develops a cough, sob, elevated BP, & distended neck veins. the nurse should expect a prescription for which of the following meds.
1. diphenhydramine
2. epinephrine
3. furosemide
4. lorazepam

A

furosemide — circulatory overload

74
Q

ongoing assessments when post-op

A
  1. Neuro = LOC, GCS, reflexes & movement
  2. Pain level
  3. I & O
  4. Bowel sounds & abdominal distention
  5. dressing & drainage
75
Q

treating post-op paralytic illeus

A
  1. offer ice chips first
  2. water second
  3. ambulation
  4. prokinetic agent
  5. NGT to decompress stomach
76
Q

s/s of pneumonia

A

*post op complication

crackles

INCREASED
- respiratory rate
- temperature
- heart rate

77
Q

s/s of shock

A

hypotension
tachycardia
decreased urinary output
lethargy
cool & pale skin

78
Q

s/s of venous thromboembolism

A

redness & edema
warmth
calf tenderness
pain

79
Q

3 types of drains

A
  1. penrose drain (stick)
  2. Jackson- pratt (light bulb)
  3. hemovac (accordian)
  • 30 ml per hour MAX
80
Q

catheter types & must always be flushed with

A

subclavian vein
internal jugular vein

*10cc flush w normal saline

81
Q

in preventing an air embolism w a CVAD

A
  1. instruct client to hold breath while pulling out
  2. reverse trendleberg position
  3. head turned away from site
82
Q

phlebitis and nursing actions

A

course of vein = red, tender, warm, & painful

  1. stop infusion
  2. flush
  3. discontinue & use WARM compress
83
Q

nursing interventions for air embolism

A
  1. clamp catheter
  2. position client in left lateral trendelenberg
  3. give O2
84
Q

s/s for air embolism

A

decrease in o2 sat
hypotension
tachycardia
dyspnea
chest pain

85
Q

s/s for pneumothorax & nursing interventions

A

s/s = dyspnea, chest pain, decreased breath sounds on one side

  1. elevate HOB
  2. admin O2
  3. discontinue catheter
    3.notify & assist
86
Q

nursing interventions for catheter related bloodstream infection

A
  1. discontinue catheter
  2. apply warm compress
  3. culture tip of catheter
  4. admin antibiotic & antipyretic
87
Q

blood donation matching

A

NEGATIVES match w/ negatives (itself & O)
POSITIVES match w/ both (+ & -) of itself

88
Q

INR range

A

0.7 to 1.8

Med Surg 1 (8 decks)

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