This list is not a guarantee of final exam content. It is meant to help the student focus study time on important content, but may not include all elements of final exam questions. The final exam is cumulative and the student is responsible for all material covered in the course. Remember the emphasis is on assessment and nursing interventions.

50-60 Questions

2 hours

The following are the topics to be covered on the final and general areas of concentration:

Med-Math calculations

·  dosage calculations

·  drip factor

·  flow rates

·  intake and output

Give amikacin 800 mg IVPB, now

Available: Amikacin 500 mg/2 ml

Set and solution: D5W 150 ml minibag and a drop factor of 15 gtt/ml set

Instructions: Infuse over 60 min

a. / Drug dose?
b. / Flow rate?

I and O’s:

1 ounces = 30 ml

Any items that is liquid form at room temperature:

ex. pudding, jello, ice cream, ice

Intravenous Infusions and Blood Transfusions

·  care and assessment of IV sites and tubing

Complication / Finding / Treatment / Prevention
Infiltration / pallor, local swelling at the site, decreased skin temperature around the site, damp dressing, slowed infusion / • stop the infusion and remove the catheter.
• elevate the extremity.
• encourage active range of motion.
• apply warm compresses three to
four times/day.
• restart the infusion proximal to the
site or in anoth / • Carefully select site and catheter.
• secure the catheter.
phlebitis/
thrombophlebitis / edema; throbbing, burning, or pain at the site; increased skin
temperature; erythema; a red line up the arm with a palpable band
at the vein site; slowed infusion / • promptly d/c the infusion and remove the catheter.
• elevate the extremity.
• apply warm compresses three to four times/day.
• restart the infusion proximal to the site or in another extremity.
• Culture the site and catheter if drainage is
present. / • rotate sites at least every 72 hr.
• avoid the lower extremities.
• use hand hygiene.
• use surgical aseptic technique.
hematoma / ecchymosis at site / • do not apply alcohol.
• apply pressure after iv catheter removal.
• use warm compress and elevation after
bleeding stops. / • minimize tourniquet time.
• remove the tourniquet before
starting iv infusion.
• maintain pressure after iv catheter removal.
Cellulitis / pain; warmth; edema; induration; red streaking; fever, chills, and malaise / • promptly d/c the infusion and
remove catheter.
• elevate the extremity.
• apply warm compresses three to
four times/day.
• Culture the site and cannula if drainage is
present.
• administer:
- antibiotics
- analgesics
- antipyretics / • rotate sites at least every 72 hr.
• avoid the lower extremities.
• use hand hygiene.
• use surgical aseptic technique.
fluid overload / distended neck veins,
increased BP, tachycardia, SOB, crackles in the lungs,
edema / • stop infusion.
• raise the HOB
• assess vital signs.
• adjust rate as prescribed.
• administer diuretics if prescribed. / • use an infusion
pump.
• monitor i&o.
Catheter embolus / missing catheter tip when discontinued; severe pain at the site with migration, or no symptoms if no migration / • place the tourniquet high on the extremity to limit venous flow.
• prepare for removal under x-ray or via surgery.
• save the catheter after removal to determine the cause / • do not reinsert the stylet into the
catheter.

·  steps in transfusion of blood and blood products

BEFORE DIFFUSION / During Infusion / Post infusion
1) The nurse will assess laboratory values.
Many institutions have specific guidelines for blood product transfusions (e.g platelet count <20,000 or hemoglobin <6g/dL).
Hematocrit –
Females: 37%-47%
Increased: Fluid shift, dehydration
Decreased: Hemorrhage
Hemoglobin -
Females: 12-16 g/dL
Increased: Fluid shift, dehydration
Decreased: Hemorrhage
Potassium -
Females: 3.5-5.0 m/Eq/L or mmol/L
Increased: dehydration, acidosis
2) The nurse will verify the medical prescription.
Legally, a blood transfusion requires physician’s prescription. The prescription will have the type of product, dose and
transfusion time.
3) The nurse will explain the procedure to the patient. The nurse will assess the patient’s vital signs before beginning the transfusion and then assess urine output, skin color, and history of transfusion reactions.
Assess whether or not the patient is able to handle the infusion. Gather prior data about previous infusion allows a nurse to be aware of signs of transfusion reaction.
4) The nurse will obtain venous access. Ideally, the nurse will use a central catheter or at least a 20-gauge needle.
This prevents the cells from getting stuck.
5) The nurse will obtain blood products from a blood bank. Then transfuse immediately.
Transfusion must occur ASAP once the blood product leave the blood bank.
6) Two nurses must verify the patient by name and number, check blood compatibility, and note expiration time. The nurse explains the procedures to the patient.
This decreases the chance of ABO incompatibility reactions. / 7) The nurse will administer the blood product using the appropriate filtered tubing.
The filters remove aggregates and possible contaminants.
8) If dilution is necessary, dilute with normal saline only.
Other IV solution will
destroy the blood product.
Infuse blood product at the prescribed rate. Begin the infusion slowly
Remain w/pt for the first 15-30 min & monitor:
- VS (then q1hr afterward). For older adult pts, assess VS more frequently b/c changes in pulse, B/P, & RR may indicate fluid overload or may be the sole indicators of a transfusion rxn. Older adult pts w/cardiac or renal dysfunction are at an increased risk for heart failure & fluid-volume excess when receiving a blood transfusion.
- rate of infusion
- respiratory status
- sudden increase in anxiety
- breath sounds
- neck-vein distention
Ask pt to report unusual sensations (like chills, SOB, hives, or itching)
Notify the primary health care provider immediately if any signs of a rxn occur
If there are no signs of a rxn, increase transfusion rate to 1 unit in about 2 hrs depending on pt's cardiac status
Complete the transfusion w/in a 2-4 hr time frame to avoid bacterial growth. / • Obtain the pt's VS upon completion of the transfusion
• Dispose of the blood-administration set appropriately (biohazard bags)
• Monitor blood values as prescribed (CBC, H+H; Hgb levels should rise by ~1 g/dL w/each unit transfused)
• Complete paperwork & file in the appropriate places
Document the pt's response

·  know reactions and interventions for blood transfusions

When Given / How Supplied / How Given / Nursing Considerations
Whole Blood / To restore blood volume (to maintain b/p). Excessive blood loss caused by injury or surgery. Hgb 6-10 g/dL, depending on symptoms / 450-500 mL
usually from blood donors of the same blood type / Transfusions take 1 to 4 hours, depending on how much blood and what type is given, and no special recovery time is needed. / Most of the time whole blood is not used because the patient's medical condition can be treated with a blood component and too much whole blood can raise a recipient's blood pressure. High blood pressure can have medical side effects
Packed RBCs
Most common blood component given. / Given to replace cells lost due to trauma, surgery or conditions that destroy RBCs or impair RBC maturation.
Anemia (Hgb 6-10 g/dL, depending on symptoms)
Chronic renal failure / Supplied in 250ml bags. / Infuse with special tubing.
Requires ABO compatibility. / Given to patients with HGB < 8g/dL or who are hypoxemic.
Actually a transplant of tissue.
Platelets / Given to pts with:
PLT counts < 10,000 mm3
or who have thrombocytopenia or platelet dysfunction (platelets < 20,000 or < 80,000) and have active bleeding.
or are scheduled for an invasive procedure. / Packed in bags of 300ml from pooled donors or 200ml from a single donor. / Infused over 15-30-minute period.
Infuse with special tubing. / Include on the labels:
• either: platelets, pooled, buffy coat derived, leukocyte-depleted
or: platelets, apheresis, leucocyte-depleted;
• volume;
• blood component producer’s name;
• either: a unique pool or batch number
or: the donation number of all contributing units
or: the donation number and, if subdivided, the sub
batch number;
• the ABO group;
• the RhD group stated as positive or negative;
• the expiry date;
• the blood pack lot number.
• store at 22˚C ± 2˚C with continuous gentle agitation;
• always check the patient ⁄ component compatibility ⁄ identity;
• inspect pack for signs of deterioration or damage;
• risk of adverse reaction ⁄ infection.
Granulocytes / For clients with infections. / Suspended in 400ml plasma. / Infuse in 45-60 minutes. / Take VS q15min throughout the transfusion.

Transfusion Reactions and Complications:

Cause / Manifestations / Priority Nursing Action / Treatment
Febrile
30 min – 6 hr after transfusion / Occur most often in pts w/anti-WBC antibodies, which can develop after multiple transfusions / Chills, tachycardia, fever, hypotension, & tachypnea / 1. D/C the transfusion immediately.
2. Give antipyretics as ordered.
3. Notify the physician.
4. KVO w/a NS infusion. / Giving leukocyte-reduced blood or single-donor HLA-matched platelets reduces the risk for this type of rxn
WBC filters may be used to trap WBCs & prevent their infusion into the pt
Hemolytic
Onset may be immediate (acute- ) or after subsequent units have been transfused / Blood type or Rh incompatibility. When blood containing antigens different from the pt's own antigens is infused, antigen-antibody complexes are formed in his/her blood. These complexes destroy the transfused cells & start inflammatory responses in the blood vessel walls & organs. / Mild: fever & chills
Life-threatening: disseminated intravascular coagulation (DIC: a pathological activation of coagulation mechanisms → formation of small blood clots inside the blood vessels throughout the body. Small clots consume coagulation proteins and platelets, normal coagulation is disrupted and abnormal bleeding occurs from the skin (e.g. from sites where blood samples were taken), the GI tract, resp tract, and surgical wounds. The small clots also disrupt normal blood flow to organs (such as the kidneys), which may malfunction as a result. Occurs acutely but also on a slower, chronic basis. Common in the critically ill, and may participate in the development of multiple organ failure which may lead to death) & circulatory collapse
Other manifestations:
– apprehension
– headache
– chest pain
– low back pain
– tachycardia
– tachypnea
– hypotension
– hemoglobinuria
– a sense of impending doom / 1. D/C the transfusion immediately. When the transfusion is d/c, the blood tubing must be removed as well. Use new tubing for the NS infusion.
2. KVO w/NS, or according to agency protocol.
3. Send the remaining blood, a sample of the client’s blood, and a urine sample to the laboratory.
4. Notify the physician immediately.
5. Monitor VS.
6. Monitor fluid I&O. / Replace donor blood w/ NS
Furosemide may be administered to increase renal blood flow.
Low-dose dopamine may be considered to improve renal blood flow.
Maintain urine output at 30-100 mL/hr
To prevent a hemolytic rxn, check the blood type or Rh compatibility with another RN before transfusion.
Allergic
Mild: during or up to 24 hr after transfusion / Mild:
sensitivity to infused plasma proteins.
------
Severe:
antibody-antigen reaction / Mild:
Flushing, itching, urticaria, bronchial wheezing
------
Severe:
Dyspnea, chest pain, circulatory collapse, cardiac arrest / Mild:
1. Stop/slow the transfusion, depending on agency protocol.
2. Notify the physician.
3. Administer medication (antihistamines) as ordered.
------
Severe:
1. Stop the transfusion
2. KVO w/NS
3. Notify the physician immediately.
4. Monitor VS Administer CPR if needed.
5. Administer medications and/or oxygen as ordered. / Mild:
Administer antihistamines.
Although the necessity of stopping the transfusion is unclear, in more severe cases and in uncertain cases, the transfusion should be stopped.
Pts w/a hx of allergy can be given leukocyte-reduced or washed RBCs in which the WBCs & plasma have been removed. This procedure reduces the possiblity of an allergic rxn.
Anaphylaxis or -phylactic
Immediate onset / Type I hypersensitivity reaction (in this case, to whole blood, cryoprecipitate, immune serum globulin—all of which is probably a result of direct mast cell degranulation rather than an IgE-mediated hypersensitivity event)
Occurs systematically (affects many organs) w/in seconds-minutes of exposure to allergen / Wheezing, dyspnea, chest tightness, cyanosis, & hypotension. / Stop the transfusion immediately.
Maintain airway; give O2 & IV fluids
Administer epinephrine, antihistamines (diphenhydramine), corticosteroids, & vasopressors.
Maintain intravascular volume. / Administer epinephrine, antihistamines (diphenhydramine), corticosteroids, & vasopressors.

o  Chart 22-2 Emergency Care of the Pt w/ Anaphylaxis

§  Immediately assess the respiratory status, airway, and oxygen saturation of pts who show any symptom of an allergic reaction

§  Call Rapid Response Team

§  Ensure that intubation and tracheotomy equipment is ready

§  Apply oxygen using a high-flow, non-rebreather mask at 40% to 60%

§  Immediately discontinue the IV drug of a pt having an anaphylactic reaction to that drug. Do not discontinue the IV, but change the IV tubing and hang normal saline.

§  If the pt does not have an IV, start one immediately and run normal saline

§  Be prepared to administer diphenhydramine (Benadryl) and epinephrine IV

·  Diphenhydramine 25 mg to 50 mg IV push

·  Epinephrine 1:1000 concentration, 0.3 to 0.5 mL IV push

·  Repeat as needed every 10 to 15 min until the pt responds

§  Keep the head of the bed elevated about 10 degrees of hypotension is present; if BP is normal, elevate the HOB to 45 degrees or higher to improve ventilation

§  Raise the feet and legs

§  Stay w/ the pt

§  Reassure the pt that the appropriate interventions are being instituted

·  steps in transfusion of blood and blood products

·  know reactions and interventions for blood transfusions

·  ~ focus on BLOOD. Packed RBCS, whole blood,

·  ~ not cryoprecipitate, fresh frozen plasma

Clients Having Surgery

·  pre-op assessment of high risk for intraoperative complication

o  ~ what would keep pt from going to surgery