Christine Vanguardia

8/12/2019 Christine Vanguardia

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1.) The nurse has obtained a unit of blood from the blood bank and has checked the bloodbag properly with another nurse. Just before the beginning transfusion, the nurse

assessess which of the following items?

A. Vital signs B. Skin Color C. Urine ouput D. Latest hematocrit level.

Correct Answer A Rationale: Change in vital signs during the transfusion from the baseline may

indicate that a transfusion reaction is occuring. This is why nurse assesses vital signs before theprocedure and again after 15 mintues. The other options do not identify assessment that are

required just before beginning a transfusion

2.) The physician orders 2 units of packed RBCs to be administered to the client. At 0600 thenight shift nurse initiates the first unit's transfusion before going off shift. At 1000 the day shift

nurse notes the IV line has clotted off and the transfusion has not been completed. The nursing

assessment revealed the transfusion was only approximately 75% complete. Which of the actions

by the nurse is most appropriate?

A. Advise the blood bank about the delay for the next unit.

B. Restart another peripheral line with 0.9% NS and restartthe blood transfusion with the remaining blood unit.

C. Discontinue the transfusion.

D. Document the amount infused thus far and continue the transfusion."

Answer CRationale: A unit of blood should be administered

within a 4 hour period of time. The nurse should discontinue the

transfusion, document the findings and notify the blood bank. The

agency policy will need to be followed concerning the documentation

process and notification of appropriate personnel. Continuing thetransfusion with the "open" unit will expose the client to an increase

risk of injury."

3.)The client with O+ blood is in need of an emergency transfusion but the lab does not have any

O+ blood available. Which potential unit of blood could be given to the client?

1. 0- unit 2. A+ unit 3. B+ unit 4. Any Rh+ unit

Correct answer: Answer 1.Rationale :1. O- negative blood is considered the universal donor

because it does not contain the antigens A, B, or Rh. (AB+is considered the universal recipient because a person with this blood type has all the anti-gens

on the blood).

2.A+ blood contains the antigen A that the client will react to, causing the development of

antibodies. The unit being Rh+

is compatible with the client.

3.B+ blood contains the antigen B that the client will react to, causing the development of anti-


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bodies. The unit being Rh+

is compatible with the client.

4.This client does not have antigens A or B on the blood. Administration of these types would

cause an antigen/antibody reaction within the client's body, resulting in a massive hemolysis of

the client's blood and death.

4.) About ten minutes after the nurse begins an infusion of packed RBCs, the patient complains

of chills, chest and back pain, and nausea. His face is flushed, and he's anxious. Which is the

priority nursing action?

1. Administering antihistamines STAT for an allergic reaction.

2. Notifying the physician of a possible transfusion reaction.3. Obtaining a urine and serum specimen to send to the lab immediately.

4. Stopping hte transfusion and maintaining a patent IV catheter.

The correct answer is 4.Rationale: The patietn is experiencing a transfusion reaction. Theimmediate nursing action is to stop the transfusion and maintain a patent IV line. The other

options may be indicated but aren't the priority in this case.

5.) The nurse is administering packed red blood cells (PRBCs) to a client. The nurse should

first:

"1. Discontinue the I.V. catheter if a blood transfusion reaction occurs.

2. Administer the PRBCs through a percutaneously inserted central catheter line with a 20-gauge

needle.

3. Flush PRBCs with 5% dextrose and 0.45% normal saline solution.

4. Stay with the client during the first 15 minutes of infusion.

Correct: 4 Rationale:The most likely time for a blood transfusion reaction to occur is during the

first 15 minutes or first 50 mL of the infusion. If a blood transfusion reaction does occur, it isimperative to keep an established I.V. line so that medication can be administered to prevent or

treat cardiovascular collapse in case of anaphylaxis. PRBCs should be administered through a

19-gauge or larger needle; a peripherally inserted central catheter line is not recommended, inorder to avoid a slow flow. RBCs will hemolyze in dextrose or lactated Ringer's solution and

should be infused with only normal saline solution.

6.) A unit of packed red blood cells has been prescribed for a client with low hemoglobin and

hematocrit levels. The nurse notifies the blood bank of the order, and a blood specimen is drawn

from the client for typing and cross-matching. The nurse receives a telephone call from the bloodbank and is informed that he unit of blood is ready for administration. Arrange the actions inorder of priority that the nurse should take to administer the blood.

a) hang the bag of blood

b) obtain the unit of blood from the bankc) ensure that an informed consent has been signed

d) verify the physician's order for the blood transfusion


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e) insert an 18 or 19-gauge IV catheter into the client

f) ask a licensed nurse to assist in confirming blood compatibility and verifying client identity.

Answer:F, D, B, A, C, E Rationale: The nurse would first verify the physician's order for theblood transfusion and ensure that the client has been informed about the procedure and has

signed an informed consent. Once this has been done, the nurse would ensure that at least an 18-

or 19-gauge intravenous needle is inserted into the client. Blood has a thicker and stickierconsistency than intravenous solutions and using an 18- or 19-gauge catheter ensures that the

bore of the catheter is large enough to prevent damage to the blood cells. Next, the blood is

obtained from the blood bank, once the nurse is sure that the client has been informed and has anadequate access for administering the blood. Once the blood has been obtained, two registered

nurses, or one registered and a licensed practical nurse (depending on agency policy), must

together check the label on the blood product against the client's identification number, blood

group, and complete name. This minimizes the risk of error in checking information on the bloodbag and thereby minimizes the risk of harm or injury to the client. The nurse should measure

vital signs and assess lung sounds and then hang the transfusion."

7.) The nurse enters a client's room to assess the client, who began receiving a blood transfusion45 minutes earlier, and notes that the client is flushed and dyspneic. On assessment, the nurse

auscultates the presence of crackles in the lung bases. The nurse determines that this client mostlikely is experiencing which complication of blood transfusion therapy?

1) Bacteriemia. 2) Hypovolemia. 3) Fluid overload 4) Transfusion reaction

Correct: 3

Rationale:With fluid overload, the client has the presence of crackles in addition to dyspnea. Anallergic reation, a type of blood transfusion reaction, would produce symptoms such as flushing,

dyspnea, itching, and a generalized rash. Hypovolemia is not complication of blood transfusions.

With bacteriemia, the client would have fever, a symptom not presented

8.) What is the nurse's primary concern regarding fluid & electrolytes when caring for an elderly

pt who is intermittently confused?

1. risk of dehydration

2. risk of kidney damage

3. risk of stroke4. risk of bleeding

Answer: 1 Rationale 1: As an adult ages, the thirst mechanism declines. Adding this in a pt with

an altered level of consciousness, there is an increased risk of dehydration & high serumosmolality.

Rationale 2: The risks for kidney damage are not specifically related to aging or fluid &

electrolyte issues.Rationale 3: The risk of stroke is not specifically related to aging or fluid & electrolyte issues.

Rationale 4: The risk of bleeding is not specifically related to aging or fluid & electrolyte issues.


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9.) A pt, experiencing multisystem fluid volume deficit, has the symptoms of tachycardia, pale,

cool skin, & decreased urine output. The nurse realizes these findings are most likely a directresult of which of the following?

1. the body's natural compensatory mechanisms2. pharmacological effects of a diuretic

3. effects of rapidly infused intravenous fluids4. cardiac failure

Answer: 1 Rationale 1: The internal vasoconstrictive compensatory reactions within the body are

responsible for the symptoms exhibited. The body naturally attempts to conserve fluid internallyspecifically for the brain & heart.

Rationale 2: A diuretic would cause further fluid loss, & is contraindicated.

Rationale 3: Rapidly infused intravenous fluids would not cause a decrease in urine output.

Rationale 4: The manifestations reported are not indicative of cardiac failure in this pt.

10.) A pregnant pt is admitted with excessive thirst, increased urination, & has a medicaldiagnosis of diabetes insipidus. The nurse chooses which of the following nursing diagnoses asmost appropriate?

1. Risk for Imbalanced Fluid Volume

2. Excess Fluid Volume

3. Imbalanced Nutrition

4. Ineffective Tissue Perfusion

Answer: 1 Rationale 1: The pt with excessive thirst, increased urination & a medical diagnosis of

diabetes insipidus is at risk for Imbalanced Fluid Volume due to the pt &'s excess volume loss

that can increase the serum levels of sodium.Rationale 2: Excess Fluid Volume is not an issue for pts with diabetes insipidus, especially

during the early stages of treatment.

Rationale 3: Imbalanced Nutrition does not apply.Rationale 4: Ineffective Tissue Perfusion does not apply

11.) A pt recovering from surgery has an indwelling urinary catheter. The nurse would contact

the pt's primary healthcare provider with which of the following 24-hour urine output volumes?

1. 600 mL2. 750 mL

3. 1000 mL

4. 1200 mL

Answer: 1 Rationale 1: A urine output of less than 30 mL per hour must be reported to the

primary healthcare provider. This indicates inadequate renal perfusion, placing the pt atincreased risk for acute renal failure & inadequate tissue perfusion. A minimum of 720 mL over

a 24-hour period is desired (30 mL multiplied by 24 hours equals 720 mL per 24 hours).


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12.) A pt is receiving intravenous fluids postoperatively following cardiac surgery. Nursing

assessments should focus on which postoperative complication?

1. fluid volume excess

2. fluid volume deficit3. seizure activity

4. liver failure

Answer: 1 Rationale 1: Antidiuretic hormone & aldosterone levels are commonly increased

following the stress response before, during, & immediately after surgery. This increase leads to

sodium & water retention. Adding more fluids intravenously can cause a fluid volume excess &stress upon the heart & circulatory system.

Rationale 2: Adding more fluids intravenously can cause a fluid volume excess, not fluid volume

deficit, & stress upon the heart & circulatory system.

Rationale 3: Seizure activity would more commonly be associated with electrolyte imbalances.Rationale 4: Liver failure is not anticipated related to postoperative intravenous fluid

administration.

13.) A pt is diagnosed with hypokalemia. After reviewing the pt's current medications, which of

the following might have contributed to the pt's health problem?

1. corticosteroid

2. thiazide diuretic

3. narcotic4. muscle relaxer

Answer: 1 Rationale 1: Excess potassium loss through the kidneys is often caused by such meds

as corticosteroids, potassium-wasting diuretics, amphotericin B, & large doses of someantibiotics.

Rationale 2: Excessive sodium is lost with the use of thiazide diuretics.

Rationale 3: Narcotics do not typically affect electrolyte balance.Rationale 4: Muscle relaxants do not typically affect electrolyte balance.

14.) A pt prescribed spironolactone is demonstrating ECG changes & complaining of muscle

weakness. The nurse realizes this pt is exhibiting signs of which of the following?

1. hyperkalemia2. hypokalemia

3. hypercalcemia

4. hypocalcemia

Answer: 1 Rationale 1: Hyperkalemia is serum potassium level greater than 5.0 mEq/L.Decreased potassium excretion is seen in potassium-sparing diuretics such as spironolactone.

Common manifestations of hyperkalemia are muscle weakness & ECG changes.

Rationale 2: Hypokalemia is seen in non-potassium diuretics such as furosemide.


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Rationale 3: Hypercalcemia has been associated with thiazide diuretics.

Rationale 4: Hypocalcemia is seen in pts who have received many units of citrated blood & is

not associated with diuretic use.

15.) When child abuse is suspected, the nurse knows that abusive burns will?

A. Have a # of scarsB. Have identifiable shapesC. Display an erratic patternD. Be one side of the body

ANSWER-B RATIONALE: typical of child abuse have symmetrical shapes and resembles the

shape of the item used to burn the child. When a child is burn accidently, the burns form an

erratic pattern and are usually irregular or asymmetrical.

16.) An 8 mos old infant was initiated. Which observation the nurse makes indicates an

improvement in the infants status?

A. Fontanels are depressedB. Infant has gained 3oz since yesterdayC. Skin remains pulled together after being gently pinched and releaseD. The infants hematocrit is greater today than yesterday

ANSWER-B

RATIONALE: A weight gain would suggest greater circulating volume. Blood has weight

17.) An example of drug used in circulating fluid volume.

A. Dopamine (intropin)B. Dobutamine (dobutrex)C. Lasix (furosemide)D. Digoxin (digitoxin)E.

ANSWER-C RATIONALE: furosemide is a diuretic w/ decrease fluid volume by increasing

renal water excretion.

18.) When assessing for complications associated of hyperparathyroidism, the nurse shouldmonitor the client for:

A. TetanyB. Cheyosteks signC. Graves diseaseD. Bone destruction

ANSWER-D RATIONALE: hyperparathyroidism causes calcium release from the bones,leaving them porous and weak.


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19.) What electrolyte imbalance is present in blood glucose level of 750mg/dl?

A. Metabolic acidosisB. Respiratory acidosisC.

Metabolic alkalosisD. Respiratory alkalosis

ANSWER-A RATIONALE: excess production of metabolic acids such as hyperglycemia in

patients w/ IDDM warrants use of fats which liberates ketone bodies which is a metabolic acid

precipitates metabolic acidosis.

20.) Most appropriate nursing intervention to correct metabolic alkalosis is to:

A. Infuse potassium chlorideB. Use of antacids and bicarbonate of sodaC. Ivf w/ bicarbonates and lactate

ANSWER-A RATIONALE: infusion of acidifying agents are beneficial to counteract metabolic

alkalosis

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Christine Vanguardia