FUNDAMENTALS OF NURSING (SACI Course Audit)Post Test

HISTORICAL BACKGROUND NURSING

1. Which of the following is the exact order of the 5 Major Dimensions/Periods in the History and Development of Nursing?

A.Educative,Intuitive,Apprentice,Dark,Contemporary

B.Intuitive, Apprentice,Dark,Educative,ContemporaryC.Contemporary,Dark,Educative,Apprentice,Intuitive

D.Intuitive,Apprentice,Educative,Dark,Contemporary

2. In a Medical-Surgical Unit, the staff nurses are very particular with the provision of the RIGHT ENVIRONMENT to their patients. The act of utilizing the environment of the patient to assist him in his recovery is theorized byA.Nightingale B.NeumanC.King D.Leininger

Nightingale environmental theory

Neuman Stress Reduction TheoryKing Goal attainment theory

Leininger Transcultural theory3. Which of the following nursing theorists conceptualized the model for determining whether a patient is on wholly compensatory, partially compensatory or supportive educative state?A. Sister Callista RoyB. Dorothea OremC. Dorothy JohnsonD. Jean Watson

Roy adaptation model

Orem self care. Self care deficit and theory of nursing systems

Johnson behavioural model

Watson humanistic caring theory

4. Which of the following is a conservation principle by Myra Levine?

A. Conservation of Structural IntegrityB. Conservation of Relativity

C. Conservation of Water

D. Conservation of Multifactorial Integrity

4 conservation principles by Myra Levine

1. Energy

2. Structural integrity

3. Personal integrity

4. Social integrity

STRESS & COPING STRATEGIES5. Stress is endemic to every persons daily life. The following are physiologic responses to stress, EXCEPT:A. Diaphoresis

B. Bronchodilation C. Dilation of PupilsD. Increased Salivation6. When the General adaptation syndrome is activated, FLIGHT OR FIGHT response sets in. Sympathetic nervous system releases norephinephrine while the adrenal medulla secretes epinephrine. Which of the following is true with regards to that statement?A. Pupils will constrictB. Client will be lethargicC. Lungs will bronchodilate D. Gastric motility will increaseRationale: To better understand the concept : The autonomic nervous system is composed of SYMPATHETIC and PARASYMPATHETIC Nervous system. It is called AUTONOMIC Because it is Involuntary and stimuli based. You cannot tell your heart to kindly beat for 60 per minute, Nor, Tell your blood vessels, Please constrict, because you need to wear skirt today and your varicosities are bulging. Sympathetic Nervous system is the FIGHT or FLIGHT mechanism. When people FIGHT or RUN, we tend to stimulate the ANS and dominate over SNS. Just Imagine a person FIGHTING and RUNNING to get the idea on the signs of SNS Domination. Imagine a resting and digesting person to get a picture of PNS Domination. A person RUNNING or FIGHTING Needs to bronchodilate, because the oxygen need is increased due to higher demand of the body. Pupils will DILATE to be able to see the enemy clearly. Client will be fully alert to dodge attacks and leap through obstacles during running. The client's gastric motility will DECREASE Because you cannot afford to urinate or defecate during fighting nor running.7. Which of the following response is NOT expected to a person whose GAS is activated and the FIGHT or FLIGHT response sets in?A. The client will not urinate due to relaxation of the detrusor muscleB. The client will be restless and alertC. Clients BP will increase there will be vasodilation D. There will be increase RR due to bronchodilation

Rationale: If vasodilation will occur, The BP will not increase but decrease. It is true that Blood pressure increases during SNS Stimulation due to the fact that we need more BLOOD to circulate during the FIGHT or FLIGHT Response because the oxygen demand has increased, but this is facilitated by vasoconstriction and not vasodilation. A,B and D are all correct. The liver will increase glycogenolysis or glycogen store utilization due to a heightened demand for energy. Pancrease will decrease insulin secretion because almost every aspect of digestion that is controlled by Parasympathetic nervous system is inhibited when the SNS dominates.

8. The primary substance responsible for dilating blood vessels during inflammatory response is:A. EndorphinB. Epinephrine C. SerotoninD. Bradykinin 9. The first manifestation of inflammation isA. Redness on the affected areaB. Swelling of the affected areaC. Pain, which causes guarding of the areaD. Increase heat due to transient vasodilation

PRINCIPLES OF PRECAUTIONS AND INFECTION CONTROL10. Kenneth has developed diarrhea from ROTAVIRUS. What type of precaution measures are to be instituted?

A. Contact, gloves, gown, gogglesB. Airborne, N95 maskC. Contact, surgical maskD. Droplet, surgical mask 11. Mark has been diagnosed to have Whooping cough. What type of precaution must be instituted?

A. Droplet, surgical maskB. Contact, gloves, gowns, gogglesC. Airborne, N95D. Contact, surgical mask 12. The most effective way to break the chain of infection is by:

A. Wearing glovesB. Hand hygieneC. Placing clients in isolationD. Providing private rooms for clientsFUNDAMENTAL HUMAN NEEDS: OXYGENATION

**NOTE: ACTUAL BOARD EXAM QUESTION JUNE2008 & 2009 NLE!13. The nurse is evaluating a clients lung sounds. Which of the following breath sounds indicate adequate ventilation when auscultated over the lung fields?

A. Vesicular

B. Bronchial

C. Bronchovesicular

D. Adventitious

Normal:

There are two normal breath sounds.Bronchialandvesicular. Breath sounds heard over thetracheobronchial treeare called bronchial breathing and breath sounds heard over the lung tissue are called vesicular breathing. The only place where tracheobronchial trees are close to chest wall without surrounding lung tissue are trachea, right sternoclavicular joints and posterior right interscapular space. These are the sites where bronchial breathing can be normally heard. In all other places there is lung tissue and vesicular breathing is heard.

The bronchial breath sounds over the trachea has a higher pitch, louder, inspiration and expiration are equal and there is a pause between inspiration and expiration.

Thevesicular breathingis heard over the thorax, lower pitched and softer than bronchial breathing. Expiration is shorter and there is no pause between inspiration and expiration. The intensity of breath sound is higher in bases in erect position and dependent lung in decubitus position.

The breath sounds are symmetrical and louder in intensity in bases compared to apices in erect position. No adventitious sounds are heard.

Breath Soundsby Dr David W.Cugell NW University Chicago

SITUATION: John Mark is 21 year old male client who was rushed following an automobile accident. He is very anxious, dyspneic and in severe pain. Refer to question numbers 14-1514. To ensure that the system is functioning effectively, the nurse should:

A. Observe for intermittent bubbling in the water seal chamber

B. Flush the chest tube with 30 to 60 mL of NSS every 4 hours

C. Maintain the client in a side-lying position always

D. Strip the chest tube in the direction of towards the client15. JMs chest tube is said to be functioning correctly when which of the following is observed?

A. Continuous bubbling in the waterseal chamber

B. Fluctuation in the water seal chamber

C. Drainage chamber more than 100ml/hr

D. Absent breath sounds heard in all lung fields

Closed chest drainage.One or more tubes may be inserted to:1. Restore intrapleural pressure2. Allow re-expansion of lungs3. Prevents air and fluid from returning to the chest

Tube to drain air is located near apex (top); to drain fluid is located near base (bottom). A chest tube that allows air to escape from the chest will be placed anterior and superior in the chest because air within the pleural space will rise to the highest point in the chest. A chest tube to drain fluid or blood will be placed posterior and inferior because fluid will collect in the most dependent part of the pleural space.

The insertion site should be covered with airtight dressingtubes are usually sutured in place. Tape all connections to ensure they do not become loose. The chest drainage system should always be keptbelowthe level of the chest.

Tubing:1. Should be coiled on the bed.2. No dependent loops.3. Avoid kinks in tubing.4. Do NOT milk clots from line.

Pleurovac Three chambers.1. Drainage chamber (look right to left)2. Water seal3. Suction

The water seal chamberacts as a one-way valve (air goes out, none goes in).Monitor for continuous bubbling in the water seal chamber.Bubbles on forceful expiration or coughing, not normal otherwise. Intermittent bubbling in water seal chamber with forced expiration or cough is OK. Continuous bubbling in the water seal isabnormaland indicates an air leak.IF the nurse notes that there is CONTINUOUS bubbling in the water seal chamber, check for leaks in the system.With physicians order, RN places padded clamp closest to dressing. If leak stops, air leak is at insertion site. If bubbling continues, leak is between clamp and drainage system.

Water should rise and fall in water seal (undulate) with respirations due to pressure changes in pleural space.Undulation: increase with inspiration, decrease tidal wave with expiration.

No fluctuations or tidal undulations in water seal:1. Tube is kinked2. Pt laying on tube3. Fluid in the tube4. Lung fully expanded (blocking the tube eyelets)

Suction chamber:While suction is applied, it is normal to have gentle bubbling in the suction chamber.Suctioncan be applied to enhance pressure differences. Very low wall suction: 5-10 mm Hg. There will be gentle bubbling (should not be vigorous bubbling) in the suction chamber.

Drainage collection chamber:Do not empty the contents. Monitor chest tube drainage q 15 minutes for at least 4 hours then at hourly intervals, for the first 24 hours, depending on the amount of drainage. Record hourly drainage.Mark level of drainage with marker on drainage collection chamber.Should NOT be more that 100 ml/hr.Over 100 ml/hris excessivenotify physician.After first 24 hours, assess drainage every 8 hours.

Junctions at tube connectors are taped to avoid dislodgement.If chest tube becomes dislodged:> Cover area with sterile (preferably Vaseline or another occlusive type) gauze.> Clamps are kept at bedside is system is disrupted or to facilitate device change.SITUATION: Respiration is one of the most important vital sign. This is usually the first vital sign to be assessed more than anything for it easily altered by the patients consciousness. The nurse should be aware of the different changes and alteration in respiration. Refer to question numbers 16-1816. Another name for an abnormal breath sound is:

A. Adventurous breath sound

B. Excursion

C. Adventitious breath sound

D. Dyspea

17. If the nurse will auscultate the base of the base of the lungs, it is expected that she will hear:

A. Bronchovesicular

B. Tubular

C. Vesicular

D. Crackles

18. The respiratory center is found in the:

A. Substancia nigra

B. Hypothalamus

C. Medulla

D. Lungs

Situation: Richard has a nursing diagnosis of ineffective airway clearance related to excessive secretions and is at risk for infection because of retained secretions. Part of Nurse Marios nursing care plan is to loosen and remove excessive secretions in the airway. Refer to question numbers 19-2319. Nurse Mario listens to Richards bilateral sounds and finds that congestion is in the upper lobes of the lungs. The appropriate position to drain the anterior and posterior apical segments of the lungs when Nurse Mario does percussion would be:

A. Client lying on his back then flat on his abdomen on Trendelenburg positionB. Client seated upright in bed or on a chair then leaning forward in sitting position then flat on his back and on his abdomenC. Client lying flat on his back and then flat on his abdomenD. Client lying on his right then left side on Trendelenburg position

20. When documenting outcome of Richards treatment, Nurse Mario should include the following in his recording EXCEPT:

A. Color, amount and consistency of sputumB. Character of breath sounds and respiratory rate before and after procedureC. Amount of fluid intake of client before and after the procedureD. Significant changes in vital signs

21. When assessing Richard for chest percussion or chest vibration and postural drainage, Nurse Mario would focus on the following EXCEPT:

A. Amount of food and fluid taken during the last meal before treatmentB. Respiratory rate, breath sounds and location of congestionC. Teaching the clients relatives to perform the procedureD. Doctors order regarding position restrictions and clients tolerance for lying flat22. Nurse Mario prepares Richard for postural drainage and percussion. Which of the following is a special consideration when doing the procedure?

A. Respiratory rate of 16 to 20 per minuteB. Client can tolerate sitting and lying positionsC. Client has no signs of infectionD. Time of last food and fluid intake of the client

23. The purpose of chest percussion and vibration is to loosen secretions in the lungs. The difference between the procedures is:

A. Percussion uses only one hand while vibration uses both handsB. Percussion delivers cushioned blows to the chest with cupped palms while vibration gently shakes secretion loose on the exhalation cycleC. In both percussion and vibration the hands are on top of each otherand hand action is in tune with clients breath rhythm

D. Percussion slaps the chest to loosen secretions while vibrationshakes the secretions along with the inhalation of air

FUNDAMENTAL HUMAN NEEDS: NUTRITION

24. Which Vitamin is not given in conjunction with the intake of LEVODOPA in cases of Parkinsons Disease due to the fact that levodopa increases its level in the body?A. Vitamin B1B. Vitamin B2C. Vitamin B3D. Vitamin B6

25. A nurse is assessing for correct placement of a nasogastric tube. The nurse aspirates the stomach contents and checks the contents for pH. The nurse verifies correct tube placement if which pH value is noted?

A. 3.5B. 7.0

C. 7.35

D. 7.5

Answer: ARationale: If the nasogastric tube is in the stomach, the pH of the contents will be acidic. Gastric aspirates have acidic pH values and should be 3.5 or lower. Option 2 indicates a slightly acidic pH. Option 3 indicates a neutral pH. Option 4 indicates an alkaline pH.

26. Among the following foods, which has the highest amount of potassium?A. Baked potatoB. OrangeC. Medium apricotD. Banana

27. Which of the following provides the richest source of Iron per area of their meat?A. Pork meatB. Lean read meatC. Pork liverD. Green mongo

FUNDAMENTAL HUMAN NEEDS: BOWEL/FECAL ELIMINATION

28. What is the duration of a RETENTION enema?

A.5-10 minutes

B.1-3 hoursC.5-10 seconds

D.1-3 minutes

CONCEPT 7: FUNDAMENTAL HUMAN NEEDS: ELIMINATION

***NOTE: ACTUAL BOARD EXAM QUESTION JUNE 2007 NURSING PRACTICE I NLE!

29. The following are appropriate nursing intervention during colostomy irrigation EXCEPT:A. Position client in semi-Fowler

B. Insert 2-4 inches of an adequately lubricated catheter to the stoma

C. Increase the irrigating solution flow rate when abdominal cramps is felt

D. Hang the solution 18 inches above the stoma

CORRECT ANSWER: C

ANALYSIS:

OPTION A - Position client in semi-Fowler

**Place client comfortably in any of the following positions in irrigating colostomy, (place linen saver under client if performing procedure in bed)

On commode

Sitting on chair facing toilet

In side-lying position turned towards the side of stomal opening, with head of bed elevated 30 to 45 degrees

In supine position

RATIONALE: Provides for effective irrigation

OPTION B - Insert 2-4 inches of an adequately lubricated catheter to the stoma- Gently insert 3 to 4 inches of irrigation tubing through cone opening into stoma; if tubing does not ease into opening, do not force

RATIONALE: prevents injury to stomal or bowel tissue

OPTION C - Increase the irrigating solution flow rate when abdominal cramps is felt If client complains of cramping, STOP the infusion for several minutes; then resume infusion SLOWLY.

RATIONALE: Allows bowel time to adjust to fluid

OPTION D - Hang the solution 18 inches above the stoma Position irrigation bag (with tubing attached) at a height of 18 inches above the stoma (approximately shoulder level)

RATIONALE: Avoids undue pressure on mucosal tissues from rushing of fluid

OPTIONS A, B and D are correct procedures for irrigating colostomy except option C.

*Nurses Guide to Clinical Procedures by Lippincott Company Jean Smith-Temple and Joyce Young Johnson, 2nd ed. 1994, p. 326-329

Situation Mrs. Seva, 52 years old, asks you about possible problems regarding her elimination now that she is in the menopausal stage. Refer to question numbers 30-3430. Instruction on health promotion regarding urinary elimination is important. Which would you include?A. Hold urine as long as she can before emptying the bladder to strengthen her sphincter musclesB. If burning sensation is experienced while voiding, drink pineapple juiceC. After urination, wipe from anal area up towards the pubisD. Tell client to empty the bladder at each voiding31. Mrs. Seva also tells the nurse that she is often constipated. Because she is aging, what physical changes predispose her to constipation?A. inhibition of the parasympathetic reflexB. weakness of sphincter muscles of anusC. loss of tone of the smooth muscles of the colonD. decreased ability to absorb fluids in the lower intestines

32. The nurse understands that one of these factors contributes to constipation:A. excessive exerciseB. high fiber dietC. no regular time for defecation dailyD. prolonged use of laxatives33. Mrs. Seva talks about fear of being incontinent due to a prior experience of dribbling urine when laughing or sneezing and when she has a full bladder. Your most appropriate instruction would be to:A. tell client to drink less fluids to avoid accidentsB. instruct client to start wearing thin adult diapersC. ask the client to bring change of underwear just in caseD. teach client pelvic exercise to strengthen perineal muscles34. Mrs. Seva asked for instructions for skin care for her mother who has urinary incontinence and is almost always in bed. Your instruction would focus on prevention of skin irritation and breakdown by:A. Using thick diapers to absorb urine wellB. Drying the skin with baby powder to prevent or mask the smell of ammoniaC. Thorough washing, rising and drying of skin area that get wet with urineD. Making sure that linen are smooth and dry at all times

35. The nurse plans to teach Michiel about colostomy irrigation. As the nurse prepares the materials needed, which of the following item indicates that the nurse needs further instruction?A. Plain NSS / Normal SalineB. K-Y JellyC. Tap waterD. Irrigation sleeve

Rationale: The colon is not sterile, nor the stomach. Tap water is used in enema irrigation and not NSS. Although some clients would prefer a distilled, mineral or filtered water, NSS is notalways necessary. KY Jelly is used as the lubricant for the irrigation tube and is inserted3-4 inches into the colostomy pointing towards the RIGHT. Irrigation sleeve is use todirect the flow of the irrigated solution out of the stomach and into the bedpan or toilet.36. The nurse should insert the colostomy tube for irrigation at approximately? A. 1-2 inchesB. 3-4 inchesC. 6-8 inchesD. 12-18 inchesRationale: Remember 3-4 inches. They are both used in the rectal tube and colostomy irrigation

tube insertion. 1 to 2 inches is too short and may spill out the irrigant out of the stoma.

Starting from 6 inches, it would be too long already and may perforate the bowel.37. The maximum height of irrigation solution for colostomy is?A. 5-10 inchesB. 12-18 inchesC. 18-24 inchesD. 24-30 inches38. An abdomino-perineal resection with a transverse colostomy is planned for an adult client. Neomycin sulfate p.o. is ordered prior to surgery. The primary purpose for administering this drug is to reduce:A. electrolyte imbalances.B. bacterial content in the colon.C. peristaltic action in the colon.D. feces in the bowel.39. The nurse knew that the normal color of Michiels stoma should be?A. Beefy RedB. GrayC. BlueD. Pale Pink

Rationale: The stoma should be RED in color. Pale pink are common with anemic or dehydratedpatients who lost a lot of blood after an operation. Blue stoma indicated cyanosis oralteration in perfusion. Stomas are not expected to be Gray.BLOOD TRANSFUSION

**NOTE: ACTUAL BOARD EXAM QUESTION 2008 NLE!SITUATION: Maxima, an ER nurse is preparing her equipments for blood transfusion to a patient who has massive bleeding due to vehicular accidents. Refer to question numbers 40-4240. The only solution compatible during blood transfusion?

A.Lactated ringers

B.Balance multiple solution

C.Normal salineD.Tap water

41. The KVO rate of BT is?

A.30 gtts/min

B.20 gtts/min

C.10 gtts/minD.100 gtts/min42. Following surgery, the client requires a blood transfusion. The main reason the nurse wants to complete the unit transfusion within a four-hour period that blood:

A. Hanging for longer than 4 hours creates an increased risk of sepsis

B. May clot in the bag

C. May evaporate

D. May not clot in the recipient after this time period

Situation - As a nurse you have to be prepared to care for patients receiving blood transfusion. The physician has ordered 3 units of whole blood to be transfused to Diego following a repair of a dissecting aneurysm of the aorta. Refer to question numbers 43-4643. You are preparing a unit of whole blood for transfusion. From the time you obtain it from the blood blank how long should you infuse it?

A. 4 hours

B. 1 hour

C. 2 hours

D. 6 hours

Rationale:

Procedure for blood transfusion :

1. Identify the patient by asking the patient their name and date of birth while comparing it to the hospital ID band. Ensure the Blood ID Band is on the patients wrist as this band has their unique R identifier number on it.

2. The patient should be assessed prior to requesting blood products. Assessment should include temperature. If oral temperature is 100 degrees Fahrenheit or higher, clarify with patients physician whether or not to proceed with the transfusion.

3. Verify that blood product received is product that was ordered. Refer to Blood and Blood Components Identification (blo02) to verify that the blood product received is in date, is labeled for the intended patient, has been crossmatched for the intended patient, and that all identifying information on the product bag tag corresponds with the information on the patients band. In the case of autologous blood, and if the patient is able, ask the patient to state his/her social security number on the blood unit label. Two nurses, one of whom is an RN, must verify the ordering information against the delivered product, and the identification of the patient. The unique R number on the pink Blood ID band must match the R number on the blood bag tag. DO NOT PROCEED WITH THE TRANSFUSION IF THESE R NUMBERS DO NOT MATCH.

4. If there is a problem with identification of the blood component, return the component to the blood bank immediately.

5. Document on the bag tag, the date, the time the unit was started, the patients vital signs and the signatures of the transfusionist and verifying nurse.

NOTE: Take and document the patients vital signs before the transfusion, 10 minutes after initiating the transfusion and upon completion of the transfusion. Vital signs should be taken more often whenever indicated. Document any abnormal

findings.

6. For gravity infusion, verify that the Y tubing of the blood set has been primed with saline. Using aseptic technique, attach the blood bag to the other side of the Y tubing. Clamp tubing on saline side and open clamp on blood bag side to allow blood to infuse.

7. For electronic controller infusion, verify that the primary set has been primed with normal saline as well as the blood secondary set. Using aseptic technique, attach the blood bag to the secondary blood set and connect the

secondary port at the cassette.

8. Begin infusing blood slowly at no greater than 2ml/min (blood tubing is 10 drops/ml so 2 ml/min equals 20 drops per minute which equates to 120 ml/hour on the electronic controller). Remain with the patient while the first 15 to 30 ml of blood infuses. During this time, observe patient closely for signs of complications.

9. Assess the patient ten minutes after initiating the transfusion, including vital signs. Document any abnormal findings. If patient is tolerating the transfusion and no signs of reaction are observed, the rate of infusion may be increased to a rate the patient can tolerate.

10. After increasing the infusion rate, remain with the patient while the next 20 to 30 ml of blood infuses.

11. Observe the patient during the transfusion at least every thirty minutes, or more often if indicated. Verify that the blood is infusing continually. Adjust drip rate as needed and according to the patients currentcondition.

NOTE: A unit of blood must be infused within four (4)hours. (CORRECT ANSWER) Options B, C and D if not lacking but exceed the time allowed for blood transfusion and it may cause any adverse reactions if it exceeds 4 hours.12. Transfuse blood completely. Flush with normal saline to clear tubing.

13. Change the blood tubing as follows:

a. After the saline flush this follows the blood transfusion.

b. Between units of multiple transfusions if the total tubing use time will exceed four hours.

CAUTION NOTE: The risk of hemolysis and bacterial contamination rises dramatically after

four hours from the presence of residual blood in the tubing.

c. If clots develop or the filter clogs.

14. Continue with patients previous intravenous orders, insert a PRN Adapter or discontinue the access as appropriate to the patients orders.

15. Following transfusion, complete the bag tag, including the time the unit is finished, patients vital signs and volume transfused. Remove bag tag from the bag and attach to the laboratory mounting form in the chart.

16. Place the empty blood bag and used tubing in a biohazardous waste bag and take to the Soiled Utility Room and dispose of in a waste container designated for biohazardous waste. These containers will be lined with red plastic bags.

NOTE: If a second unit is being administered and the tubing is not being changed, plug the open port of the empty blood bag with a needle cap before discarding the bag

(http://www.smh.com/sections/servicesprocedures/medlib/nursing/Procedures/Blood/AdminRed_blo03_112105.pdf)

44. As Diegos nurse what will you do after the transfusion has been started?

A. Discontinue the primary IV of Dextrose 5% water

B. Stay with Diego for 15 minutes to note for any possible BT reaction

C. Check his vital signs every 15 minutes

D. Add the total amount of the blood to be transferred to the intake and outputAnswer: B

Rationale: Monitor and document vital signs every 5 minutes for the first 15 minutes assessing for chilling, back pain, head ache, nausea or vomiting, tachycardia, hypotension, tachypnea, or skin rash. Altered vital signs or other adverse reactions are early indications of a transfusion reaction. Infusing blood slowly during this period limits the amount of blood the client receives if there is a reaction.

Reference: Craven, Ruth F. & Constance J. Hirnle, Fundamentals of Nursing: Human Health and Function, Lippincott Williams &Wilkins, 4th ed. 2003 page 605

45. Diego is undergoing blood transfusion of the first unit. The earliest signs of transfusion reactions are

A. Oliguria and jaundice

B. Urticaria and wheezing

C. Hypertension and flushing

D. Headache, chills and feverAnswer: D

Rationale: Acute transfusion reactions present as adverse signs or symptoms during or within 24 hours of a blood transfusion. The most frequent reactions are fever, chills, urticaria, or shortness of breath, which resolve promptly without specific treatment or complications. More serious reactions, such as hemolysis or sepsis, are potentially fatal.

Transfusion reactions require immediate recognition, laboratory investigation, and clinical management. If a transfusion reaction is suspected during blood administration, the safest practice is to stop the transfusion and keep the intravenous line open with 0.9% sodium chloride (normal saline). A clerical check of the blood unit label and patient should be performed. In most cases, the blood product should be returned to the blood bank, and a transfusion reaction investigation should be initiated.Acute transfusion reactions may present in complex clinical situations when diagnosis requires distinguishing between a reaction to the transfused blood product and a coincidental complication of the illness being treated that occurs during or immediately after a blood transfusion.

In option C, hypertension rarely exists in transfusion reaction, instead there is HYPOTENSION as a part of anaphylactic reaction of the body to transfusion of blood.

(http://www.emedicine.com/med/topic2297.htm)

46. In case Diego will experience an acute haemolytic reaction, what will be your priority intervention?

A. Immediately stop the blood transfusion, infuse Dextrose 5% in water and call the physician

B. Slow the blood transfusion and monitor the patient closely

C. Immediately stop the blood transfusion, notify the blood bank and administer antihistamines

D. Immediately stop the blood transfusion, infuse normal saline solution, call the physician, notify the blood bank

Answer: D

Rationale: Acute hemolytic reaction

most serious among acute transfusion reactions and can be life threatening. occurs when the donors blood is incompatible with the recipients blood

always monitor vital signs before starting the infusion and during the first five minutes when the blood is infusing slowly. If you suspect a hemolytic reaction, stop the transfusion immediately and keep the IV open with normal saline.

Reference: Craven, Ruth F. & Constance J. Hirnle, Fundamentals of Nursing: Human Health and Function, Lippincott Williams &Wilkins, 4th ed. 2003 page 607

47. Which of the following is the correct procedure in transfusing Fresh Frozen Plasma?

A.Confirm doctors order after gathering materials

B.Get baseline vital signs after the transfusion

C.Administer Fresh Frozen Plasma for the first 15 minutes, then transfuse according to the computed rate if there will be no adverse reaction

D.Administer Fresh Frozen Plasma immediatelyFLUIDS AND ELECTROLYTES

48. The nurse assesses a client to be experiencing muscle cramps, numbness, and tingling of the extremities, and twitching of the facial muscle and eyelid when the facial nerve is tapped. The nurse reports this assessment as consistent with which of the following?

A. Hypokalemia

B. Hypernatremia

C. Hypermagnesemia

D.Hypocalcemia49. The nurse writes the nursing problem of fluid volume excess (FVE). Which intervention should be included in the plan of care?

A.Change the IV fluid from 0.9% NSS to D5W

B.Restrict the clients sodium in the diet.C.Monitor blood glucose level

D.Prepare the client for hemodialysis

50. The client has been vomiting and has had numerous episodes of diarrhea. Which laboratory test should the nurser monitor?

A.Serum Calcium

B.Serum Phosphorus

C.Serum potassiumD.Serum sodium