Nurse Esther listens to liebermans abdomen. Which of the following sounds is an expected
finding for Lieberman? - ANS C
She's feeling lightheaded and dizzy. Her skin is pale. Priority action? - ANS Measure Ms.
Leibermans vital signs
She's feeling worse. Nurse Esther starts oxygen at 2L/min. Priority action? - ANS lower the
head of the bed
Preparing to administer a unit of packed RBC's. What should she do prior to administering the
blood? - ANS Ask Ms. Lieberman if she has experienced a reaction with any previous blood
transfusions
Identify correct sequence of actions after nurse Esther performs hand hygiene and applies
gloves. - ANS (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 RBC's. (4) attach the packed RBC's bag to the y- tube setting.
(5) turn off the 0.9% sodium chloride solution. (6) infuse the packed RBC's .
Patient is restless, her face is flushed, and she reports having a headache. Which of the
following is an appropriate action for nurse Esther to take? - ANS Stop the blood transfusion.
Using SBAR format... - ANS S- 836 year old client admitted from the emergency department
today for a G.I. bleed. She had one pack of red blood cells. I stopped at the second one
because she was having a transfusion reaction.
b- she has a history of Crohn's disease and intermittent gastritis. Her last infusion was seven
weeks ago
A- her hemoglobin was 7 g/dL and her hematocrit was 21% in the ED. At this time her
respirations are 26 and her SaO2 is 97%
R- She is requesting ibuprofen for her headache.
Nurse Esther is reinforcing teaching. Which of the following should the nurse Esther include in
the teaching? - ANS A medication to reduce oral secretions may be administered
Preparing to administer morphine 4 milligrams through IV. Available morphine is 8 mg/mL. How
many ML should the nurse administer. - ANS 0.5
Preparing to administer 4 mg of morphine IV bolus. Which of the following actions should she
take? - ANS Infuse morphine at a rate of 1 mg/min.
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