Fifteen minutes after beginning a transfusion of O negative blood to a patient in shock, the nurse assesses a drop in the patient's blood pressure to 60/40 mm Hg, heart rate 135 beats/min, respirations 40 breaths/min, and a temperature of 102° F
The nurse notes the new onset of hematuria in the patient's Foley catheter. What are the priority nursing actions? (Select all that apply.) a. Administer acetaminophen (Tylenol).
b. Document the patient's response.
c. Increase the rate of transfusion.
d. Notify the blood bank.
e. Notify the physician.
f. Stop the transfusion.
B, D, E, F
In the event of a reaction, the transfusion is stopped, the patient is assessed, and both the physician and laboratory are notified. All transfusion equipment (bag, tubing, and remaining solutions) and any blood or urine specimens obtained are sent to the laboratory according to hospital policy. The events of the reaction, interventions used, and patient response to treatment are documented. Acetaminophen is not warranted in the immediate recognition and treatment of a transfusion reaction. The infusion must be stopped. Increasing the infusion further increases the likelihood of worsening the transfusion reaction.
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1. Vital signs 2. Dietary habits 3. Impairments 4. Medication history 5. Height
When putting a client in restraints, the nurse will need to assess the client per policy. Which items will the nurse include when assessing this client?
Select all that apply. 1. The client's range of motion 2. That the client's restraint is tied in a knot 3. The client's vital signs 4. The client's circulation 5. The client's hydration
A nurse preceptor asks a new graduate nurse to identify the different types of mastectomy surgeries. Which response by the new graduate would indicate that further clarification is needed? Select all that apply
a. Simple d. Modified radical b. Radical e. Cross-sectional c. Modified Simple f. Subcutaneous
An older patient is being admitted to a long-term care facility. The nurse recognizes that the primary purpose of the initial geriatric health assessment is to
a. identify the patient's physiologic base-lines. b. ultimately create a plan of care that pre-vents disability and dependence. c. initiate the therapeutic nurse-patient rela-tionship. d. document self-care deficiencies that the patient exhibits.