ATI real life RN : GI Bleed 3.0

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Nurse Esther listens to Ms. Lieberman's abdomen in all four quadrants and determines Ms. Lieberman's bowel sounds are hyperactive. Listen to the 4 audio clips. which of the following sounds is an expected finding for Ms. Lieberman:

A, B, C, D
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Ms. Lieberman reports feeling worse and her vital signs are: BP 94/56 mm Hg, pulse 110/min, RR 26/min, and SaO2 94%. Nurse Esther starts oxygen at 2 L/min. Which of the following should be Nurse priority action?

A. recheck Ms. Lieberman's oxygen sat
B. check output from Ms. Lieberman's ostomy
C. lower the head of bed
D. send the AP to pick up blood
Nurse Esther is preparing to administer a unit of packed RBCs to Ms. Lieberman. Which of the following actions should Nurse Esther perform prior to administering the blood?

A. infuse 0.9% sodium chloride IV solution remaining in the bag, prior to initiating the transfusion

B. ask Ms. Lieberman if she has experienced a reaction with any previous blood transfusions

C. ensure Ms. Lieberman's sister signs the consent form

D. perform verifications process with an AP
B. ask Ms. Lieberman if she has experienced a reaction with any previous blood transfusions

rationale: a transfusion reaction can be caused by the dvlpmt of antibodies to the donor leukocytes. this reaction is more likely to occur when a pt has had blood transfusions before as well as a hx of prior blood transfusion rx.
1. Spike and prime the Y-set tubing with the 0.9% sodium chloride solution.

2. Attach the tubing to the IV catheter and begin to infuse the 0.9% sodium chloride solution.

3. Gently rotate the bag of packed RBCs.

4. Attach the packed RBCs bag to the Y-set tubing.

5. Turn off the 0.9% sodium chloride solution.

6. Begin to infuse the packed RBCs
Nurse Esther notes Ms. Lieberman is restless, her face is flushed, and reports having a headache. VS: temp 38.8C (101.8F), pulse 96/min, RR 22/min, and BP 103/60 mm Hg. Which of the following is an appropriate action for Nurse Esther to take?

A. decrease the rate of transfusion and reassess vs in 15 min

B. infuse 50 mL of 0.9% sodium chloride solution and then restart the transfusion at a slower rate

C. increase the rate of the infusion so all the blood will transfuse in the next 15 min

D. stop the transfusion
S: Dr. McGuire, this is Esther - RN. I am taking care of Ms. Lieberman in room 5206. She is a 36-year-old client admitted from the ED today for a GI bleed. She's had one unit of packed RBCs and part of the second unit of blood. I stopped the second unit because I believe she is having a transfusion reaction. Her baseline temperature was 98.6 and is now 101.8. Ms. Lieberman reports having a headache, chills, and is restless. She does not have any evidence of a rash at this time.B: Ms. Lieberman has a history of Crohns disease and intermittent gastritis. Six months ago she had an ileostomy and started on infliximab IV every 8 weeks. Her last infusion was 7 weeks ago.A: Her hgb was 7 g/dL and her hct was 21% in the ED. When she arrived to the medical surgical unit, her BP was 94/56 and her pulse 110, but now her BP is 110/70 and her pulse is 110. At this time, her respirations are 26, her SaO2 is 97%, and her temperature is 101.8. I have discontinued the second unit of blood and plan to send both the bags of blood to the lab per protocol. I hung a new bag of 0.9% sodium chloride to keep the line open.R: Ms. Lieberman is requesting ibuprofen for her headache, which would also bring her fever down. Could I have an prescription for an antipyretic, and do you want to continue the IV infusion of 0.9% sodium chloride at 150 mL/hr?
Nurse Esther is reinforcing teaching with Ms. Lieberman, who is scheduled for an endoscopy in the morning. Which of the following should Nurse Esther include in the teaching?

A. "a laxative will be given to clear the bowel"

B. "you will be placed on your right side during the procedure"

C. "you will be able to resume your full-liquid diet as soon as the procedure is completed"

D. "a meds to reduce oral secretions may be administered"
Nurse Esther is preparing to admin 4 mg of morphine IV bolus to Ms. Lieberman. which of the following actions should nurse Esther take?

A. infuse morphine at a rate of 1 mg/min

B. dilute the med in at least 2 mL of sterile water

C. ensure atropine (Sal-Tropine) is available prior to admin the morphine

D. inject the med in the port on the IV tubing furthest from the IV insertion site
Ms. Lieberman tells Nurse Esther she has a stressful job working in the city as a stockbroker, and that sometimes at night she has up to five drinks. Which of the following is an appropriate statement made by Nurse Esther? A. i know managing stocks must be difficult, because i struggle to manage my own money B. we need to talk more about your drinking before you are discharged C. you need to stop drinking that much. have you thought about going to AA D. tell me more about the stress you are feelingD. tell me more about the stress you are feelingidentify 5 stress management strategies nurse Esther should recommend to Ms. Lieberman to promote a healthier lifestyle1. perform light regular exercise 2. write in a journal 3. listen to music 4. consider a pet 5. get adequate sleep 6. promote relaxation through muscle relaxation, guided imagery, massage therapy, humor, yoga 7. enhance social support 8. evaluate current job, lifestyle, and home locationNurse Esther is reinforcing diet teaching with Ms. Lieberman. Which of the following dietary recommendations should she make? A. eat foods that are high protein B. include foods higher in fiber, such as corn c. limit caffeine intake to 200 mg a day D. limit intake of complex carbsA. eat foods that are high proteinNurse Esther provides Ms. Lieberman with info about health promo. which of the following should she include in the teaching? A. urge to run 30 min, 3 times a week B. advise to avoid the use of ibuprofen C. tell her she is at risk for developing hearing loss while she is taking infliximab (Remicade) D. encourage to limit fluid intake to decrease the ostomy outputB. advise to avoid the use of ibuprofen