Exam 4 - NUR 340 Practice Questions
and Correct Answers
Hemorrhage (Causes, RF, S/S, Diagnostics, Gen Treatment) ✅Causes: bleeding
inside and outside the body
RF: meds that cause bleeding, recent surgery etc.
S/S: cool moist skin, down BP, up HR, down output, delayed cap refill
Diagnostics: RBC might be falsely high for 2-3 days, low RBC, Hgb, Hct
Gen Treatment: 2 large G ivs, type and cross, fluids, modified Trendelenburg
Blood Administration (proper steps for administration) ✅Informed Consent, T&C, hang
w NS, VS within 15 mins, ID recipient
Give within 30 mins
Infusion rate no exceed 4 hours
(anyone can pick up blood from blood bank)
Febrile Nonhemolytic Transfusion Reaction (Cause, S/S, Management) ✅most
common reaction
Caused by pts sensitivity to the donor wbcs
S/S: sudden chills, fever, rigors, headache, flushing, anxiety, vomiting, muscle pain
Management: antipyretics (acetaminophen & diphenhydramine)
Acute Hemolytic Reaction (Cause, S/S, Prevention) ✅SHOULD NEVER HAPPEN
Cause: recipient's antibodies attach to antigens on rbcs
S/S: starts w chills, fever, low back pain, and flushing
Prevention is key!
(meticulous verification and documentation of pt ID)
Allergic Transfusion Reaction (S/S, prevention) ✅S/S: hives, itching, flushing
(pts often given Benadryl)
Prevention: antihistamines/corticosteroids (blood component washing)
Transfusion Associated Circulatory Overload (TACO) (RF, cause, S/S, treatment) ✅too
much too quickly
, RF: HF, RF, and age (too much fluid already)
S/S: dyspnea, orthopnea, tachycardia, up BP, sudden doom, JVD, crackles in lungs,
pulmonary edema
Diuretics (can develop as late as 6 hrs after)
Bacterial Contamination Transfusion Reaction (cause, S/S) ✅bacteria in blood
products
S/S: fever, chills, hypotension
(can lead to sepsis, take meticulous care when admin, storing etc.)
Transfusion Related Acute Lung Injury (TRALI) (S/S, diagnostics, treatment) ✅(MORE
SEVERE)
Develop acute lung injury
S/S: dyspnea, hypoxia, hypotension, fever, pulmonary edema
Diagnosis: chest x-ray
Treatment: quick supportive care
NO DIURETICS
What to do for Infusion Reaction ✅- STOP INFUSION
- maintain IV acess w saline (change tubing)
- notify blood bank and physician
- recheck ID
Etc.
Obesity (BMI ranges)
<18.5
18.5 - 24.9
25.0 - 29.9
30.0 - 34.9
>35 ✅<18.5 = increase intake
18.5-24.9 = maintain
25-29.9 = down intake and up exercise (OVERWEIGHT)
30-34.9 = anti obesity meds (OBESE)
>35 = surgery consult
(>40 severe/extreme obese)
