A nurse is administering packed red blood cells to a client. What should the nurse do if a
transfusion reaction is suspected? - ANS - Stop the infusion.
\A nurse is caring for a client with skeletal traction following a fracture. How and when should
skeletal pin care be provided? - ANS - One cotton swab with chlorhexidine is designated for
each pin for pin care to be done once a shift.
\A nurse is providing dietary teaching to a client newly diagnosed with constipation-predominant
irritable bowel syndrome. List two (2) teaching points the should share with the client about
dietary practices. - ANS - Eat foods high in fiber
Increase fluids
\ABGs
Determine imbalance - ANS -
\Acute appendicitis findings - ANS - fever, tachycardia, diffuse abd pain, complications:
peritonitis
\Antidiarrheal drugs - ANS - camphorated tincture of opium
diphenoxin
diphenoxylate
laudanum
loperamide hydrochloride
\Blood compatibility:
Nursing Actions for Hemolytic transfusion reaction - ANS - Remove the blood tubing from the IV
access site. Initiate an infusion of 0.9% of sodium chloride using new tubing. Monitor VS and
fluid status. Send the blood bag and administrating set to the lab for testing.
\Care of a perpherially inserted central catheter infusion system - ANS - access site for redness,
swelling, drainage, tenderness, and condition of the dressing.
\Caring for pt with peritoneal dialysis: - ANS - monitor for signs of infection (bloody, cloudy or
frothy dialysate return, monitor for complications: respiratory distress, abd pain, insufficient flow,
and discolored outflow
\Cushing's Disease findings (too much cortisol hormone) - ANS - fx or osteoporoesis,
mnemonic: STRESSED
S=skin fragile
T=truncal obesity with small arms
R=rounded face (moon shaped-like); Reproductive issues: ammenorrhea in women, erectile
dysfx in males
E=ecchymosis, Elevated BP
S=striae on the extremities and abd
S=sugar extremely high (hyperglycemia)
E=excessive body hair...Hirsutism (women starting to have male chara), and Electrolyte imbal:
hypokalemia
D=Dorsocervical fat pad (buffalo hump), Depression
\Evaluating effectiveness of fluid replacement - ANS - hematocrit, increase hypovolemia
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