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NURSING
@Ti�r10:26
Quiz-Apr29,202312:26PM
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CORRECT
► A client receiving a blood transfusion experiences a hemolytic reaction.
Which finding will the nurse expect when assessing this client?
@ 1. Hypotension, backache, low back pain, fever.
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2. Wet breath sounds, severe shortness of breath.
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3. Chills and fever occurring about an hour after the infusion started.
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4. Urticaria, itching, respiratory distress.
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1) CORRECT- Signs and symptoms of a hemolytic reaction include
chills, headache, backache, and dyspnea.
2) INCORRECT- Wet breath sounds and severe shortness of breath are
symptoms of circulatory overload.
HIDE EXPLANATION
3) INCORRECT- Chills and fever occurring about 1 hour after the
infusion started describes a febrile or pyrogenic reaction.
4) INCORRECT- Urticaria, itching, and respiratory distress describes an
allergic reaction.
-,
Th.ink Like a Nurse: Clinical Decisionis aware that a client should be closely monitored
1 '1-se
during a blood transfusion. A hemolytic transfusion reaction
is the most severe type of reaction because the immune
system breaks down red blood cells in the body due to
incompatibility with the transfused blood. Manifestations of
this type of reaction include a drop in bl1ood pressure,
backache, chills, headache, and a fever. The nurse should
stop the transfusion imm1ediately, administer oxygen, monitor
vital signs, and contact the health care provider.
► Which information is essential to report when communicating client information at the change
of shift? (Select all that apply.)
D 1. The client is newly diagnosed with type 1 diabetes and needs follow-up teaching
about insulin administration.
(C orrect}
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Client teaching needs related to discharge are important in the continuum
of care and should be communicated during the change of shift report.
2. The client is seemingly more confused and has been attempting to get out of bed
without assistance.
A behavior change and/or new symptom is essential to report during the
change of shift.
3. The attending health care provider prescribed lorazepam PRN for restlessness.
All health care provider prescriptions that are new are essential to
communicate during the change of shift report.
D 4. The client has a 20-year history of smoking.
Information that can be attained in a medical record is not essential to report. There is
no information that the smoking history presents an immediate need.
D 5. The client receives carvedilol, benztropine mesylate, and losartan on a daily basis.
As a nurse, what is your priority when communicating information at the change
of shift? Your priority is to concisely transfer client information that is essential
for the next shift to safely and effectively provide care.
Information to include during change of shift:
• Changes in the client conditions.
• Current progress toward goals.
• New prescriptions.
• Teaching needs.
Routine information can be obtained by reviewing the medical record.
Medications previously prescribed or that are routine do not need to be included
in change of shift report, unless a medication's adverse effect is being
considered as a reason for the client's change m condition
Routine medications do not need to be included in the report and can be obtained from
the medical record. Prescriptions for new medications, pertinent PRN medications
recently administered, or symptoms unrelieved by medications should be included in
the repor t
The nurse provides care to a middle-age dient hospitalized following a cerebrovascular
accident (CVA). Which information in the dient's history does the nurse recognize as being
a risk factor for experiencing a CVA? (Select all that apply.)
1 Frequent tension headaches.
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X While migraine headaches are associated with an increased risk for CVA, tension
headaches are not considered to be a risk factor.
2. Pheochromocytoma.
A pheochromocytoma is a benign (noncancerous) tumor that develops in
one or both adrenal glands. Hormones released by the pheochromocytoma
cause hypertension, which is a risk factor for CVA.
D 3. Routine use of ibuprofen.
(C orrect)
Routine use of nonsteroidal anti-inflammatory medications (NSAIDs),
such as ibuprofen, increases the risk for CVA.
D 4 Weight loss.
Weight loss does not increase the individual's risk for CVA. Appropriate weight loss
may even decrease the risk for CVA.
5. Diabetes mellitus.
Diabetes mellitus is a risk factor for vascular complications, including CVA.
Risk factors for a cerebrovascular accident include:
• Hypertension.
• Atherosclerosis.
You should remember the following points:
• Pheochromocytoma causes significant hypertension and is a risk factor for a stroke.
• Non-steroidal anti-inflammatory medication can increase blood pressure, which
increases the risk for a stroke.
• Microvascular changes can occur in individuals with diabetes mellitus. These
changes affect cerebral blood vessels, leading to thrombus formation or a cerebral
hemorrhagic event.
A cerebrovascular accident (CVA) is an interruption of blood flow in the brain
as a result of hemorrhage or thrombus. Risk factors for CVA are
• Diabetes mellitus.
• Hypertension.
• Family history.
• Cardiovascular disease.
• Atrial fibrillation.
• Increasing age.
• Hyperlipidemia
• Obesity.
• Smoking.
• Previous CVA.
• Substance abuse (e.g. alcohol and cocaine).
lschemic stroke results from blood clots that block an artery
supplying the brain. Clots form in diseased arteries when plaque
ruptures in the bloodstream. A thrombotic stroke is caused by a
blood clot (thrombus) formed in an artery supplying the brain. An
embolic stroke is caused by a moving blood clot or piece of debris
(embolus) that travels through the bloodstream before lodging in
an artery supplying the brain.
In Bipol'ar I Disorder ( B D I) clients will swing between manic episodes,
hypomanic ep.isodes, and d•epression.
M a n i c episodes are characterized b y behaviors that include:
• Elevated mood.
• Ext.ren,ely high self-esteem.
• Irritability
or anger.
• Insomnia_
• Anore.xia.
• Racing thoughts oir flight of ideas.
• Talkative, loud, and rapid speech.
• High ener-,g,y.
• High interest in sex.
• High suicide risk.
• Excessive use of makeup.
Hypoma.nic episodes are less severe and m a y appear as "normal." A n
episode lasts 4 days or more; 1itdoes not impair functioning but is observable.
S y m p t o m s of lhypomania are similar to mania and include talkativeness,
incr,eased self-esteem, racing thoug,hts, distJractibilirty, m o r e goal-oriented
behaviors, or high interest in risky lbut pleasurable activities.
R e m e m b e r that Bipolar 2 Disorder ( B D 2) disorder involves major depression
and at least one hypomanic episode, but typically d o e s not invo,lve m a n i c
episode:s.
►The nurse prepares to assess a client with right-sided heart failure Which symptom will the
nurse expect to observe?
0 1. Increased respiration with exertion.
Increased respiration with exertion is a common assessment finding of the client with
chronic lung disease.
0 2. Cough producing large amount of thick, yellow mucus.
A cough with large amounts of thick, yellow mucus describes a complication of
pneumonia.
® 3. Peripheral edema and anorexia.
Right-sided heart failure is manifested by congestion of the venous system,
resulting in peripheral edema. Also, there is congestion of the gastric veins,
resulting in anorexia and eventual development of ascites.
0 4. Twitching of extremities.
Twitching of the extremities is not a manifestation of right-sided heart failure. This
symptom may occur with multiple sclerosis.
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The heart can be viewed as a double-pump. The right side of the heart receives
fluid from the peripheral organs and tissues. The left side of the heart provides
oxygenation and nourishment to the body organs and tissues. When the right
side of the heart fails, fluid begins to backup leading to peripheral edema. This
congestion affects the gastric vasculature causing edema and ascites in the
abdomen.
Causes of right-sided heart failure:
Causes of left-sided heart failure:
• Left-sided heart failure.
• Aortic stenosis.
• Atrial septal defect.
• Cardiomyopathy.
• Cor pulmonale.
• Pulmonary hypertension.
• Pulmonary valve stenosis.
Risk factors for heart failure:
Other causes of heart failure:
• Diabetes.
• Alcohol abuse.
• Coarctation of the aorta.
• Cocaine use.
• Hypertension.
• Heart muscle infection.
• HIV/AIDS.
• Myocardial infarction.
• Thyroid disorders.
• Mitra! regurgitation.
Right-Sided Heart Failure
Left-Sided Heart Failure
• African American.
Jugular venous distension
Dyspnea on exertion
• Obesity.
Dependent peripheral edema Dry, hacking cough
• Prior myocardial infarction.
Ascites
Crackles, wheezing
• Congenital heart defects.
Weight gain
Orthopnea
Signs and symptoms of heart failure:
Hepatosplenomegaly
Paroxysmal nocturnal dyspnea
GI pain, anorexia, nausea
Cheyne-Stokes respirations
Fatigue, weakness
Cyanosis
Tachycardia
Tachypnea, tachycardia
Nocturia
Nocturia
• Over 65 years of age.
► The nurse supervises the staff providing care to four clients receiving blood transfusions.
Which client will the nurse see first?
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1. Reporting a headache.
Headache is a symptom of a febrile reaction. Additional symptoms include fever,
chills, and nausea. The treatment is to stop the blood transfusion.
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2. Experiencing back and chest pain.
Chest, flank, abdominal, and lower back pain are symptoms of a hemolytic
reaction, which is the most dangerous type of transfusion reaction. Additional
signs include hematuria, skin flushing, tachycardia, tachypnea, hypotension,
disseminated intravascular coagulation (DIC), vascular collapse, shock, and
death. Treatment is to the stop blood transfusion, obtain a urine specimen and
maintain blood volume and renal perfusion with an IV colloid solution.
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3. Reporting itching.
Itching is a symptom of an allergic reaction. Additional symptoms include urticaria,
pruritus, and fever. Treatment is to stop the blood transfusion, provide
diphenhydramine, and administer oxygen, if needed.
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4. Experiencing neck vein distention.
Neck vein distention is a symptom of circulatory overload. Treatment is to stop the
blood transfusion, position the client in an upright position, and administer oxygen.
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Each of the clients requires the nurse to intervene quickly, so you must
determine who is in the most danger. The client with chest and back pain
requires immediate intervention, as this indicates a hemolytic reaction and
cardiovascular assault with impending collapse. The body is compensating by
shifting blood flow away from non-essential functions to provide cardiac output
to the heart, brain, and lungs. This type of symptom is a warning of impending
anaphylaxis, which will compromise the client's airway
The client with a febrile reaction and the client with an allergic reaction also
need prompt attention; however, they are secondary to the client experiencing a
hemolytic reaction. The client with neck vein distention is not having a reaction
to the blood itself but is experiencing fluid volume overload. All three of these
clients will need the transfusions stopped. The client with the fluid volume
overload should be seen second - after the client experiencing a hemolytic
reaction.
Blood Transfusion Reactions with Associated Signs & Symptoms
Acute Hemolytic
Anaphylactic and Severe Allergic
• Chills.
• Anxiety.
• Low back, flank, and/or chest pain.
• Dyspnea.
• Fever.
• Wheezing progressing to cyanosis.
• Tachycardia.
• Bronchospasm.
• Dyspnea.
• Hypotension.
• Hypotension.
• Shock.
Febrile, Nonhemolytic
• Chills.
• Temperature rises > 1 degree Celsius.
• Headache.
• Anxiety.
• Nausea/vomiting.
Mild Allergic
• Flushing.
• Itching.
• Hives.
► The nurse provides care to clients in a long term care facility. Which client requires the
nurse's immediate attention?
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1. Client recovering from a cerebral vascular accident and whose prescription for
Warfarin is a potent anticoagulant used to prevent the development of clots,
which can result in stroke, myocardial infarction (Ml), deep vein thrombosis
The duration of warfarin therapy for the client recovering from a cerebral (DVT) or pulmonary embolism (PE). Warfarin does not dissolve clots.
Reaching therapeutic anticoagulation using warfarin takes several days.
(Correct) vascular (CVA) accident is 2 to 5 days. This client is at risk for another
CVA and should be assessed first.
Prothrombin time (PT) and international normalized ratio (INR) are frequently
monitored throughout treatment with warfarin. If ovcrdo c occurs, the
2. Client experiencing pain after receiving morphine in an acute care facility and who wa, antidote, which is vitamin K (phytonadione), should be administered.
warfarin expired two days ago.
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transferred with a prescription for acetaminophen with codeine.
Client requiring anticoagulation is a priority even though pain should be addressed as
soon as possible.
0 3.
X
0 4.
Client voiding foul-smelling, cloudy, dark amber urine associated with dysuria.
Foul-smelling, cloudy, dark amber urine associated with pain upon urination may
indicate an infection. This client should be assessed soon. However, this client does
not take priority over the client requiring anti-coagulation therapy.
Client needing influenza immunization because of immunosuppression.
The need for influenza vaccination is not life-threatening and does not take priority
over the client requiring anti-coagulation therapy.
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Warfarin is routinely prescribed as a treatment for ischem1dembolic stroke.
Failure to take warfarin can result in new clot formation and place the client
at risk for experiencing another stroke. This is a circulatory (C) issue and
should be assessed first. The client experiencing pain when voiding foulsmelling, cloudy, dark amber urine most likely has a urinary tract infection
and will need further assessment and intervention, but the client with a
circulatory issue takes priority.
The client experiencing pain and who is transferred to a different facility with
a prescription for a less effective analgesic will also need further assessment
and intervention but can be seen third. Remember, pain is considered
psychosocial unless it 1s described in terms such as:
• Crushing.
• Stabbing.
• Excruciating
• Unrelenting.
When descriptors such as those above are included and the pain is severe
and the pain is not responding to treatment and/or is life/limb threatening, the
pain should be considered physical. The client with the physical, circulatory
issue takes priority over the client with pain in answer option 2. Lastly, you
can follow-up with the client in need of an influenza immunization.