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NRS 222 Skills Lab Final
Terms in this set (58)
What determines a patient's blood type?
The antigens (proteins) on the surface of their RBCs
What are antibodies?
Substances in the patient's plasma that attack foreign antigens
Therefore, the patient's antibodies are OPPOSITE of the antigens on their RBCs
Type A has ___ antigen and ___ antibodies
Type B has ___ antigen and ___ antibodies
Type AB has ___ antigen and ___ antibodies
Type O has ___ antigen and ___ antibodies
No antigens on their surface
A and B antibodies
Why is AB the universal recipient
They don't have any antibodies in their plasma
Why is type O the universal donor?
type O blood does not contain A or B antigens and therefore will not react with antibodies in any recipient's blood
However, since they have both A and B antibodies, they can only recieve blood with NO antigens on their surface, i.e. type O
When determining which blood a patient can receive, the nurse must consider what?
Which ANTIBODIES that the patient has in their plasma
For example, type B blood has type A antibodies. So, they can't receive type A blood. BUT, they can receive type O, since O does not have any antigens on the surface.
When determining which blood a patient can DONATE to, look at the
When determining which blood a patient can RECEIVE, look at
Type AB blood can receive
A, B, AB, O
Type O can recieve
They have both A and B antibodies!
If a person has positive RH factor, they can receive _____?
Both positive and negative blood
If a person has negative RH factor, they can receive ___?
Rh negative blood
Why would a patient need a blood transfusion?
Low on BC
Anemia (renal failure, cancer)
How will blood transfusion affect blood pressure
Will ideally increase blood pressure
May lead to volume overload in elderly
How do blood tranfusions affect calcium and potassium levels?
The nurse should stay with the patient for ________ minutes of transfusion to detect what?
What should the nurse do PRIOR to
What should the nurse prime the blood product tubing with?
What pre-transfusion medications should the nurse administer?
Acetaminophen (20-10 minutes pre-transfusion)
What should the nurse verify at the blood bank?
• Blood group & type (ABO/Rh) of patient and blood product
• Donor (product unit) number and component type
• Cross match expiration date/time
• Transfusion product expiration date (& expiration time fWeor thawing, if applicable)
• Absence of clots in product
• Record date, time and initials of RN obtaining transfusion product from blood
The nurse should obtain and record a set of vital signs ____ minutes before transfusion
Packed RBC's should be infused over a minimum of
and should never be hung for more than
What should never be added to the blood product line?
If abx or other meds are needed, start an additional IV line
If a patient is showing signs of a transfusion reaction, _____
STOP THE INFUSION
Have diphenhydramine, epinephrine, NS, and abx readily available for PRN use
The total time that you have to complete a transfusion of red cells from the time the unit is hung is
A patient with AB pos blood has received B neg blood. What would you expect to be the outcome?
A person with blood type A will have which antibodies?
B antibodies in their plasma
How long may a blood unit be out of the transfusion service's refrigerator before it could be returned (without spiking the bag)?
How many mL/min should you infuse the PRBC's over the first 15 minutes?
If no transfusion reaction occurs within the first 15 minutes, how fast can you infuse the pRBC?
Titration is the __________________
adjustment of the dose, either increasing or decreasing, to attain the desired patient response
Central IV access should be utilized for
medications that can cause damage when extravasated
How often should you obtain vital signs when the patient is on conintuous infusion medications?
Every 1-2 hours
What is Amiodarone incompatible with?
What must be applied to both the patient and the nurse when accessing/deaccessing an implanted venous port?
Masks! Reduce infection transmission
1. What is the most common placement site for a central venous access device?
How often the Huber need and dressing should be changed on an Implanted Venous Access Device when it is being used continuously.
Every seven days unless soiled
What do you use to flush when De-Accessing an implanted port?
This minimizes the risk of blood collecting on the end of the catheter and forming a clot that prevents the catheter from functioning properly
What is the primary purpose of a PCA pump?
A PCA pump allows the patient to control their analgesia PRN.
This provides more consistent and complete pain management.
1. What protective mechanism prevents drug overdose with PCA?
The PCA pump has an onboard computer that prevents excessive medication demands until a designated lockout period has passed.
Typically, this time is set between 5 and 10 minutes
How is the risk of respiratory depression reduced with a PCA pump?
The pump can be adjusted to patient-specific factors, such as opioid tolerance and risk for respiratory depression.
The lockout period in a PCA pump refers to:
The feature on the pump that prohibits excess dosing
In order for a patient to receive a PCA bolus of medication, they must:
- be in sight of the nursing staff
- continuous pulse oximetery
When is a cosign needed with a PCA pump?
- patient handover
-any chance in the rate or dose of the medication, a - syringe change
Who is not a good candidate for PCA pump?
- Decreased AVPU
- Critically ill/unstable
- Under age of 5
For pneumothorax, the_____________intercostal space is the usual site because air rises to the top of the intrapleural space. For hemothorax or pleural effusion, the ______________ intercostal spaces are common sites because fluid settles to the lower levels of the intrapleural space.
Pneumothorax: second to third intercostal space
Hemothorax: fourth to sixth intercostal space
Which position should a patient be in during chest tube insertion?
Side lying with arm of the affected side above the head
Why is the patient asked to take a deep breath just before chest tube insertion?
If the patient can cooperate, ask him/her to take a deep breath just before tube insertion.
A deep breath displaces the diaphragm downward, minimizing the risk of injury.
Patient position for hemothorax
Patient position for pneumothorax
Which of the chambers of the chest tube drainage collection system must always have sterile water in it?
The water-seal chamber (at least 2 cm)
If you notice crepitus on assessment, what should you do?
The development of crepitus in the thoracic cavity can indicate that air is leaking into the subcutaneous tissue.
The nurse should immediately notify the primary care provider and document their findings.
It may be necessary for the surgeon to adjust the chest tube placement
What might be the possible causes for chest tube drainage to exceed 100 ml during a one hour period and what would you do about it?
If the chest tube drainage exceeds 100ml/hour, it is possible that the patient is experiencing internal hemorrhage or pleural effusion.
These findings should be promptly reported to the primary health care provider
You are caring for a patient with a Chest Tube and notice continuous bubbling in the water seal chamber. What should you do?
If the chest tube is consistently bubbling, then an air leak is present.
This will alert the nurse to assess the location of the leak by checking each of the connections from the chest tube drainage unit back to the insertion site on the patient
You come in to check on your patient that has a chest tube. The chest tube drainage system has fallen on its side and is leaking drainage on the floor from a crack in the system. What should you do?
If this occurs, the nurse should disconnect the tubing from the drainage system and insert the tubing into a bottle of sterile water.
The nurse should then obtain a new system to reattach to the patient.
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