Blood administration safety •A signed consent is required prior to administration of blood products •Consent must be signed by the patient (if over 18) or the patient's guardian that can make medical decisions for them •2 individuals confirm and document 2 patient identifiers when each of the...
NUR 436 Final Exam Questions and
Correct Answers
Blood administration safety ✅•A signed consent is required prior to administration of
blood products
•Consent must be signed by the patient (if over 18) or the patient's guardian that can
make medical decisions for them
•2 individuals confirm and document 2 patient identifiers when each of these specimens
are collected
-nurse must check patient's lab results before transfusing blood products to ensure a
type & screen and/or type & crossmatch has been ordered and performed
-•Obtain baseline vital signs before getting blood from blood bank
-administer blood within 30 minutes of receiving the product
-take vitals 5 min, 15 min, 20 min into transfusion (CANT be delegated to UAP)
-vitals then hourly after transfusion (can be delegated to UAP)
-RN must stay with pt for 15 minutes after the infusion
S/S of adverse reactions to blood products ✅n/v
burning
facial swelling
abd cramping
significant back pain
chills
diarrhea
chest pain
headache
hematuria
fever
pallor
Inc HR and BP
breathing difficulty
What to do if pt shows adverse reaction to blood transfusions ✅1.STOP the
transfusion immediately
2.Remove the blood product tubing, connect 0.9% NS tubing to the patient's IV site, and
begin 0.9% NS infusion
3.Do NOT leave the patient alone
4.Notify healthcare provider
5.Continue monitoring the patient's assessment and vital signs
6.Notify blood bank - they will tell you what labs to draw from patient and paperwork to
bring to blood bank (usually CBC and UA)
Make sure to save blood bag and tubing to send to blood bank
Administer any medications ordered by provider for adverse transfusion reaction
, Parkland fluid calculations ✅-applied in only 2nd or 3rd degree burns
-volume of lactated ringer solution: 4 mL x total BSA (%) x body weight (kg)
-first half of the solution over the first 8 hours
-second half of the solution over the next 16 hours
-patient hand = 1% of total BSA
-18% each leg
-9% each arm
-1% genital area
-18% front chest
-18% back
-9% head
Primary concerns with burns ✅-hypovolemic shock (intravascular fluid volume
depletion); dec BP inc HR
-pulm/peripheral edema
Nursing management for burns ✅1. airway management (intubation, bronchoscopy,
100% oxygen)
2. fluid therapy: two large bore IV access sites, fluid replacement (crystalloid solutions),
assess UO
3. wound care: should be delayed until a patent airway, adequate circulation, and
adequate fluid replacement have been achieved
4.ears should be kept free of pressure (no use of pillows)
5. early ROM measures
6. drug therapy: -Analgesics and sedatives
•Morphine
•Hydromorphone (Dilaudid)
•Haloperidol (Haldol)
•Lorazepam (Ativan)
•Midazolam
-antimicrobial agents
-VTE prophylaxis : heparin
7. enteral feedings (5000 kcal/day)
Red cross description ✅-Not there to treat for medical things, but can help with
resources (assist shelter residents with their self-directed medical care)
-supervised by an RN
-provide care for disaster related unmet health needs (consumable med supplies,
durable medical equipment for health maintenance)
-referrals for disaster-related medical and mental health care
-replace prescriptions, eyeglasses, prosthetic devices, hearing aids, other equipment
lost
-surveillance and disease health event reporting
-health education
-provide for staff wellness
-promote good hygiene (cleanliness of children's toys, hand sanitation etc)
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