The patient is to receive 2 units of packed RBCs. Before administering the blood, what does the nurse need to do? (Select all that apply.)
a. Insert an 18-gauge IV cannula.
b. Have the patient complete a consent form.
c. Obtain pretransfusion vital signs.
d. Notify the physician for a temperature of 37° C.
B, C
In emergency situations that require rapid transfusions, a large-gauge cannula is preferred; however, transfusions for therapeutic indications may be infused with cannulas ranging from 20 to 24 gauge. Check that the patient has properly completed and signed transfusion consent before retrieving blood. Most agencies require patients to sign consent forms before receiving blood component therapy because of the inherent risks. Obtain and record pretransfusion vital signs, including temperature, immediately before initiation of the transfusion. If the patient is febrile (temperature greater than 100? F [37.8? C]), notify the physician or the health care provider before initiating the transfusion. Change from baseline vital signs during infusion will alert the nurse to a potential transfusion reaction or adverse effect of therapy.
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A patient is transferred to the recovery room after a 4-hour surgery. Balanced anesthesia was used to produce loss of consciousness, analgesia, and muscle relaxation. In order to help prevent aspiration, the nurse will
A) assess the need for postoperative analgesia. B) monitor the patient's vital signs. C) instruct the patient to turn, cough, and deep breathe. D) position the patient in a side-lying position.
A 30-year-old patient has come to the clinic for her yearly examination. The patient asks the nurse about ovarian cancer. What should the nurse state when describing risk factors for ovarian cancer?
A) "Use of oral contraceptives increases the risk of ovarian cancer." B) "Most cases of ovarian cancer are attributed to tobacco use." C) "Most cases of ovarian cancer are considered to be random, with no obvious causation." D) "The majority of women who get ovarian cancer have a family history of the disease."
During the admitting assessment process, a client asks, "What is oliguria?" Based on the nurse's knowledge, the best response would be:
1. "Oliguria is a urine output less than 50 mL in 24 hours." 2. "Oliguria is a urine output less than 250 mL in 24 hours." 3. "Oliguria is a urine output less than 400 mL in 24 hours." 4. "Oliguria is a decreased urine output indicative of disease."
Dependence is a term that refers to the:
a. Presence and severity of withdrawal symptoms b. Necessary use of drugs to prevent withdrawal symptoms c. Level of intoxication associated with addiction d. Amount of substance needed to satisfy cravings