MedSurg Test 1 2nd Semester

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BCnurses2014
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MedSurg Test 1 2nd Semester
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2013-09-08 16:30:26
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MedSurg Test 1 2nd Semester
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  1. Why do patients need IV therapy?
    To restore/replace, to maintain fluid balance, to correct fluid/electrolyte imbalances, and as a medium for medication administration.
  2. What are isotonic IV fluids used for?
    To increase extracellular volume.
  3. What are hypotonic IV fluids used for?
    To prevent and treat cellular dehydration by providing free water to the cells.
  4. When are hypotonic IV fluids contraindicated and why?
    Hypotonic IV fluids are contraindicated in acute brain injuries because cerebral cells are very sensitive to free water, absorbing it rapidly and leading to cellular edema.
  5. What is TPN?
    Total Parenteral Nutrition contains water, protein, carbohydrates, fats, vitamins, and trace elements that are necessary to the healing process. It is a very strong hypertonic solution. It must be given through a central venous catheter to allow rapid mixing and dilution.
  6. What are the nursing interventions for TPN?
    Monitor infusion/flow rate, weigh patient daily, accurate I&O, sterile dressing changes, tubing changes every 24 hours, finger stick every 6 hours, daily electrolytes, and central line care.
  7. IV calculation equation
    • volume x gtt factor(60)
    • time in minutes
  8. What are the complications of IV therapy?
    Infiltration, phlebitis, thrombophlebitis, infection, circulatory overload, air embolism, and extravasation.
  9. What is infiltration?
    An accumulation of fluid in the tissue surrounding an IV catheter site. It is usually caused by penetration of the vein wall by the catheter and leads to dislodgment out of the vein and into the tissue.
  10. Signs and symptoms of IV infiltration:
    • Flow rate may slow or stop (IV pump will beep occlusion)
    • Site becomes cool and hard
    • Site may become pale and swollen
    • Patient may complain of pain, tenderness, burning or irritation at site
    • Fluid may leak around the site
  11. What do you do if you suspect IV infiltration?
    • Stop infusion and remove catheter
    • Elevate extremity
    • If noticed within 30 mins of onset, apply ice to decrease inflammation
    • If noticed later than 30 mins, apply warm compress to encourage absorption
    • Document
    • Restart IV in another location
  12. What measures should you take to prevent an infiltration?
    • Properly secure catheter hub to the limb
    • Stabilize extremity by applying an arm board if necessary
    • Assess site every hour
    • Keep flow rate at the prescribed rate
    • Change IV site and tubing every 72 hours
    • Avoid areas where flexion occurs
  13. What is phlebitis?
    Inflammation of the wall of the vein
  14. Signs and symptoms of phlebitis:
    • Sluggish flow rate
    • Swelling around site
    • Patient complaint of pain or discomfort at site
    • Redness and warmth along vein
  15. How would you treat phlebitis?
    • Stop infusion and remove catheter
    • Elevate extremityIf noticed within 30 mins of onset, apply ice to decrease inflammation
    • If noticed later than 30 mins, apply warm compress to encourage absorption
    • Document
    • Restart IV in another location
  16. What is thrombophlebitis?
    The presence of a blood clot and vein inflammation
  17. How would you treat thrombophlebitis?
    • Stop infusion and remove catheter
    • Elevate extremityIf noticed within 30 mins of onset, apply ice to decrease inflammation
    • If noticed later than 30 mins, apply warm compress to encourage absorption
    • Document
    • Restart IV in another location
  18. What causes circulatory overload?
    Infusion of fluids at a rate greater than the patient can tolerate
  19. Signs and symptoms of circulatory overload:
    • SOB
    • Cough
    • Moist breath sounds
    • Engorged neck veins
    • Edema
    • 3rd heart sound
  20. How would you treat circulatory overload?
    • Slow the IV rate
    • Call doctor
    • Monitor VS
    • Give diuretics as ordered
  21. What is an air embolism?
    The obstruction of a blood vessel (usually occurring in the lungs or heart) by air carried via the blood stream
  22. What causes an air embolism?
    • Failure to remove air from IV tubing
    • Allowing solution bags to run dry
    • Disconnecting IV tubing
  23. Signs and symptoms of air embolism:
    • Abrupt drop in blood pressure
    • Weak, rapid pulse
    • Cyanosis
    • Chest pain
  24. How do you prevent an air embolism?
    • Prime tubing
    • Monitor solution levels carefully and change bag before it becomes empty
    • Frequently check to assure that all connections are secure
  25. How do you treat an air embolism?
    • Notify rapid response
    • Place patient of left side with feet elevated to allow the pulmonary artery to absorb small air bubbles
    • Administer O2 prn
  26. What is extravasation?
    Leakage of a vesicant IV solution or medication into the extramuscular tissue
  27. Signs and symptoms of extravasation:
    • Flow rate may slow or stop (IV pump will beep occlusion)
    • Site becomes cool and hard
    • Site may become pale and swollen
    • Patient may complain of pain, tenderness, burning or irritation at site
    • Fluid may leak around the site
    • Tissue sloughing appears in 1-4 weeks
  28. Why are blood transfusions given?
    To restore blood volume after severe hemorrhage and to replace loss due to disease processes
  29. What is an autologous transfusion?
    Blood donated by you to you
  30. What is an allogenic transfusion?
    Donor blood
  31. What kind of blood can an Rh- patient receive?
    Only Rh- blood
  32. What kind of blood can an Rh+ patient receive?
    May receive Rh- or Rh+ blood
  33. When are packed red blood cells given (PRBCs)?
    When hgb/hct are low
  34. Packed red blood cells (PRBCs) should be administered over _____ hours.
    2-4 hours
  35. When are platelets given?
    • When platelet count is decreased such as in thrombocytopenia.
    • Platelets must be cross matched
  36. Platelets should be given over ____ minutes.
    15-30 minutes
  37. What is plasma (FFP) used for?
    • Used as a volume expander for shock, post-op, liver disease
    • Must be kept frozen until ready to use
  38. What is cryoprecipitate?
    It is derived from thawing FFP and recovering the precipitate (clotting factors)
  39. What is albumin?
    A fractionated portion of plasma used as a volume expander to support BP
  40. Before administering blood always...
    • Obtain order (type, crossmatch, and transfuse)
    • Explain procedure to patient
    • Verify consent and order
    • Obtain baseline vital signs
    • Notify blood bank
    • Have two nurses verify blood and patient
    • Administer within 30 minutes of leaving blood bank
  41. When administering blood...
    • Use an 18-20 gauge IV and correct tubing
    • Start transfusion slowly
    • Transfuse with NS
    • Change tubing after 2 units
    • Stay with patient for first 15 minutes
  42. What are the possible blood transfusion reactions?
    • Febrile reactions
    • Allergic reactions
    • Acute hemolytic reactions
    • Anaphylactic reaction
    • Circulatory overload
    • Sepsis
  43. What causes a febrile reaction to a blood transfusion?
    • Caused by antibodies to donor white blood cells
    • Most common reaction
  44. Signs and symptoms of a febrile reaction:
    • ChillsĀ 
    • Fever - Increase in body temp of 1*F within two hours after initiation of transfusion
  45. What causes an allergic reaction in a blood transfusion?
    Foreign protein sensitivity
  46. What are symptoms of an allergic reaction to a blood transfusion?
    • Uticaria
    • Flushing
  47. What causes an acute hemolytic reaction in blood transfusions?
    • Antibodies react with antigens on donor erythrocytes causing massive hemolysis
    • This is the most dangerous reaction
  48. What causes an anaphylactic reaction to a blood transfusion?
    Infusion of immune globulin A (IgA) proteins to IgA recipient with anti-IgA antibodies
  49. Signs and symptoms of an anaphylactic reaction to a blood transfusion:
    • Anxiety
    • Uticaria
    • Wheezing
  50. Signs and symptoms circulatory overload from a blood transfusion:
    • Edema
    • Increased BP and HR
    • SOB
    • Coughing
  51. How would you treat circulatory overload?
    Diuretics
  52. What causes sepsis of a blood transfusion?
    Bacterial contamination of a blood product
  53. Signs and symptoms of sepsis:
    • Chills
    • High fever
    • Vomiting
    • Diarrhea
    • Hypotension progressing to shock
  54. What should you do if your patient has a reaction to a blood transfusion?
    • Stop the transfusion
    • Keep the IV line open with a different NS bag and tubing
    • Notify doctor
    • Notify blood bank
    • Recheck blood unit identification and patients
    • Return blood and tubing, with documentation, to blood bank
    • Document using blood transfusion record
    • Remain with and treat patient per orders
    • Monitor for signs and symptoms of shock
    • Obtain blood and urine tests as ordered
    • Monitor coagulation studies if hemolytic shock is suspected
    • Monitor renal function
  55. What are some complications of epidurals?
    • Hypotension - increase IV fluids
    • Hemorrhage at insertion site - rapid surgical intervention
    • Catheter migration - can cause respiratory/cardiac arrest
    • Wet tap - tear in dura mater
    • Infection - rare
  56. Causes of fluid volume deficit (FVD):
    • Excessive fluid loss
    • Insufficient fluid intake
    • Failure of regulatory systems
    • Third spacing
  57. Signs and symptoms of fluid volume deficit (FVD):
    • Thirst
    • Dry mucous membranes
    • Decreased urinary output
    • Altered mental status
    • Fatigue
    • Dry skin, pale, cool extremities
    • Tachycardia
    • Decreased BP
    • Weight loss
  58. How do you treat fluid volume deficit (FVD)?
    • Mild - water
    • Moderate - sports drinks
    • Severe - IV fluids
  59. Signs and symptoms of fluid volume excess:
    • Weight gain in a short period
    • Distended neck and peripheral veins
    • Full bounding pulse
    • Tachycardia
    • Increase central venous pressure
    • Dyspnea with cough
    • Moist crackles, pulmonary edema
    • Polyuria
    • Ascites - third spacing
    • Peripheral edema
  60. Normal range of sodium:
    135-145 mEq/L
  61. What does sodium do in the body?
    Primary regulator of volume, osmolality, distribution of ECF, and maintain neuromuscular activity
  62. What are the causes of hyponatremia?
    • Excess sodium loss through kidneys, GI tract, skin
    • Water gains r/t renal disease, heart failure, liver failure
    • Excessive hypotonic IV fluids
  63. Signs and symptoms of hyponatremia:
    • Anorexia - GI
    • N/V - GI
    • Diarrhea, abdominal cramping - GI
    • Headache - neuro
    • Altered mental status - neuro
    • Seizure and coma - neuro
    • Muscle cramps, weakness, tremors - neuro
    • Decreased serum sodium and osmolality
  64. Causes of hypernatremia:
    • Altered thirst mechanism
    • Profuse sweating
    • Diarrhea
    • Diabetes insipidus
    • Oral electrolyte solutions
    • Excessive IV fluids
    • Inability to respond to thirst or obtain water
  65. Signs and symptoms of hypernatremia:
    • Thirst
    • Dry, sticky mucous membranes
    • Altered mental status - restlessness, decreased LOC
    • Weakness
    • Muscle twitching
    • Seizures

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