A nurse is caring for a patient receiving a transfusion and assesses that the patient is
wheezing and it's complaining of back pain. What nursing action
... [Show More] should take place after
stopping the transfusion? - ANS-Notify the charge nurse
Signs that you need to suction a patient with a tracheostomy - ANS-Pt becomes restless
and has an increase in vital signs
A nurse is completing an initial assessment on a new patient being seen in a hospital
clinic. The presentation of this female patient includes symptoms of tiredness and large
areas of ecchymosis. Which question is most important for the nurse to ask? - ANS-Do
your gums bleed easily
What is the sympathetic pain response? - ANS-Increased pulse, BP, RR, dilated pupils,
perspiration and pallor
what are the s/s of organ dysfunction? - ANS-dry mouth, thirst, sluggish pupils,
peripheral edema, muscle weakness, mental status changes, hypotension, weak and
thready pulses, increased RR, decreased urine output, cyanosis
What are the types of pain? - ANS-Acute, chronic, referred and cancer related
What assessment made by a nurse indicates that respiratory arrest is imminent? - ANSAbsence of breathing sounds
At 10 AM and I was received two units of blood for the patient to be transfused. What is
the most appropriate nursing action? - ANS-Set up one unit for the transition to start by
10:30 and send the other unit back until the first one has infused
What happens to the sickle shaped red blood cells during sickle cell crisis? - ANSobstruction of major arteries
Priority nursing diagnosis for shock - ANS-Inadequate cardiac output and risk for
impaired cardiovascular function
What information should A nurse be sure to include on preparing discharge plans for a
patient recently diagnosed with pernicious anemia? - ANS-providing sufficient rest
periods throughout the day
What is the rationale for administering injections of vitamin B 12 to patients with
pernicious anemia? - ANS-The patient may lack the intrinsic factor necessary for
vitamin B 12 absorption
Types of distributive shock? - ANS-anaphylactic, septic, neurogenic
What does hydroxyurea do? - ANS-Produce hemoglobin that resist sickling
Patho for distributive shock - ANS-excessive dilation of blood vessels or decreased
vascular resistance causing the blood to be improperly distributed
A patient with polycythemia vera will have what lab value elevated? - ANS-High Hgb
level
a nurse is caring for a patient with crushing injuries from an automobile accident and the
patient is bleeding profusely from the nose, mouth, rectum, as well as from the other
injuries. What should the nurse suspect as the cause of the patient's bleeding? - ANSDisseminated intravascular coagulation (DIC)
What is responsible for initiating the inflammatory response in addition to the
immunoglobulin E (IgE)? - ANS-Basophils
Complication of distributive shock - ANS-increased capillary permeability which permits
plasma to leak into the interstitial compartments → decreasing intravascular blood
volume
What is true concerning passive-acquired immunity? - ANS-Antibodies are acquired
from the outside the host and instilled in the host.
After a bone marrow transplant, a patient is placed on a protocol of chemotherapy and
radiation and has the potential for injury. Which nursing assessment should cause the
nurse concern? - ANS-Increasing abdominal girth
What is the primary function in the immune response? - ANS-Filter microorganisms
from the blood
What laboratory result is monitored in a patient with leukemia? - ANS-Platelet count
Causes of neurogenic shock - ANS-spinal cord injury (T4), regional anesthesia, disease
of the upper spinal cord, certain depressant drugs, adrenal insufficiency.
What are normal age-related changes of the respiratory system? - ANS-smell is not as
accurate, dry nose, occasional nose bleeds
Causes of hypotension with cervical spine injury - ANS-This is because of the loss of
nervous system control which works to keep the blood pressure stable, as well as loss
of muscle tone which helps to return blood to the heart.
A patient comes into the clinic complaining of a runny nose and facial pain. What should
the nurse's initial assessment include? - ANS-Assessment for nasal drainage and sinus
tenderness
what are the signs and symptoms of speed shock? - ANS-light-headedness, tightness in
the chest, flushed face, irregular pulse
How to prevent immobility issues - ANS-rotational bed therapy, careful positioning
active and passive exercises
What is a sign that drug protocols are not effective with acute leukemia? - ANS-Platelet
count lower than 50,000/mm3
s/s fluid volume excess - ANS-rising bp, bounding pulse, rapid respiratory, decreased
temp & edema.
What should the nurse anticipate that a positive blood analysis would show for a patient
diagnosed with HIV? - ANS-High levels of HIV-infected cells
s/s of infiltration - ANS-pain, burning sensation, pale, puffy, hard & cool.
How long does the initial stage of HIV infection usually last? - ANS-4 to 8 weeks
s/s of phlebitis - ANS-redness, swelling, warmth & tenderness.
When taking retrovir what should the nurse be especially observant for? - ANSJaundice
How to encourage urination - ANS-Placing hand in water, warm water poured over
perineum, blowing bubbles through a straw, sitting on the toilet, straight cath
What is important for an immunocompromised patient who is also diagnosed with
microsporidiosis? - ANS-Drink 3 quarts of fluid per day to combat dehydration.
What are complications of cardiac cath? - ANS-bleeding, hematoma formation,
infection, dye-induced allergic reactions (seafood/iodine), high exposure of radiation &
embolus/thrombus formation at the insertion site
What indicates a patient has entered the third stage of HIV infection? - ANS-T-helper
CD4 cell count of 500
Interventions for cirrhosis of the liver - ANS-encourage the patient to eat even if the
patient isn't hungry, arrange a dietary consult and report likes and dislikes, schedule
nursing care to encourage undisturbed rest, TCDB, relieve pruritus w. gentle bathing
with mild soap & tepid water, thorough rinsing and moisturizing, elevate the HOB to
promote breathing, handle pt gently... [Show Less]