Nur 255 B Adult Health 1 CBU

Correct Answers: Obtain a signed consent, Perform a baseline assessment, and Check for allergies.

Obtain a signed consent: A blood transfusion requires informed consent. The nurse must ensure that the client has signed the consent form, acknowledging that they understand the risks, benefits, and alternatives to the procedure.

Perform a baseline assessment: Before starting the transfusion, it is crucial to obtain baseline vital signs (temperature, pulse, blood pressure, respiratory rate, oxygen saturation) and assess the client for any signs or symptoms of fluid overload or pre-existing reactions. 

Check for allergies: The nurse must check the client's medical history for any known allergies or previous reactions to blood products. This is critical for identifying patients at higher risk of transfusion-related complications.

Explanation of Incorrect Answers:

Initiate a 22-gauge IV: A larger bore IV (18- or 20-gauge) is recommended for blood transfusion to ensure adequate flow and prevent hemolysis of red blood cells. A 22-gauge IV is too small for transfusing packed red blood cells efficiently.

Hang an IV of D5W: Blood products must be infused using normal saline (0.9% sodium chloride) as it is isotonic and does not cause hemolysis or clotting of red blood cells. D5W is contraindicated for blood transfusions.

Summary:

For a safe blood transfusion, the nurse should obtain consent, perform a baseline assessment, and check for allergies. The IV gauge must be large enough (18-20 gauge), and normal saline should be used as the compatible solution for blood product administration.

Correct Answer: To enable the patient to die with dignity

The primary goal of hospice care is to provide compassionate care to patients who are in the final stages of a terminal illness. It focuses on enabling the patient to live their remaining days with comfort, dignity, and respect, rather than pursuing curative treatments.

The aim is to support both the patient and their family during this challenging time, addressing physical, emotional, and spiritual needs.

Why the Other Options Are Incorrect:

To assemble a team to give the patient the chance of living longer:

Hospice care is not focused on extending life but on improving the quality of life during the end-of-life process. It is about comfort, not cure.

To make sure the patient has access to the latest treatments:

Hospice care focuses on comfort care and symptom management, not on offering aggressive or experimental treatments.

To ensure that the patient does not have pain on any day:

While pain management is a crucial part of hospice care, the primary goal is not just to eliminate pain but to ensure that the patient experiences comfort and dignity in their final days

Summary:

The main goal of hospice care is to help the patient die with dignity by providing comfort, support, and symptom management, allowing them to live their remaining time as fully as possible, surrounded by loved ones.

Correct Answer: Respiratory depression

Lorazepam (Ativan) is a benzodiazepine commonly used to treat anxiety, agitation, and sometimes seizures. As a CNS depressant, lorazepam can cause various side effects, but respiratory depression is one of the most significant and potentially dangerous effects.

Respiratory depression is a known risk of benzodiazepines, particularly if used in high doses, if the patient has pre-existing respiratory conditions, or if the drug is combined with other CNS depressants (e.g., opioids, alcohol). Benzodiazepines like lorazepam depress the respiratory centers in the brain, which can lead to shallow or slowed breathing, posing a risk for hypoxia.

Why the Other Answers are Not Correct:

Nausea and vomiting: While nausea and vomiting can occur with lorazepam, they are less common compared to respiratory depression, and they are not the primary concerns associated with this medication.

Confusion: Confusion or sedation can occur with lorazepam, especially in elderly patients, but respiratory depression is a more immediate and dangerous concern for this class of drugs.

Rash: Although a rash can be a side effect of lorazepam, it is rare. The most concerning side effects are typically related to the CNS and respiratory system.

Key point:

When caring for a patient on lorazepam, the nurse should monitor for signs of respiratory depression, especially if the patient is receiving other CNS depressants or has underlying respiratory issues. Other side effects like confusion and sedation are also important to monitor but are generally less life-threatening than respiratory depression.

Correct Answer: Morphine, Dilaudid (hydromorphone), Fentanyl (sublimaze)

Patient-Controlled Analgesia (PCA) pumps are used to allow patients to self-administer pain medication within prescribed limits, typically for managing moderate to severe pain after surgery or during certain medical conditions. The medications used in PCA pumps are generally opioids, which have potent pain-relieving effects.

The most common opioids used in PCA pumps include:

Morphine: A well-known opioid for moderate to severe pain, frequently used in PCA pumps.

Dilaudid (Hydromorphone): A more potent opioid than morphine, often used when stronger pain relief is needed.

Fentanyl (Sublimaze): A synthetic opioid that is also commonly used in PCA pumps, especially when rapid onset and potent pain relief are necessary.

These medications are effective and have a predictable pharmacologic effect when administered through a PCA pump, making them the most suitable choices for patient-controlled pain management.

Why the Other Options Are Incorrect:

Morphine (MS Contin), Demerol (meperidine), Vicodin (hydrocodone/acetaminophen):

MS Contin (morphine) is a long-acting opioid, but Vicodin (hydrocodone/acetaminophen) and Demerol (meperidine) are less commonly used in PCA pumps.=

Demerol (meperidine) is generally not recommended for PCA due to its potential to cause neurotoxic effects (such as seizures), especially with prolonged use.

Vicodin is a combination drug with an opioid (hydrocodone) and acetaminophen, but it is typically not used in PCA pumps due to its less potent opioid content and the acetaminophen component.

Fentanyl (Sublimaze), Demerol (meperidine), Dilantin (phenytoin):

Dilantin (phenytoin) is an anticonvulsant medication used for seizures, not a pain medication. It has no role in PCA for pain management.

Dilaudid (hydromorphone), Demerol (meperidine), Dolophine (methadone):

Demerol (meperidine) again has issues with neurotoxicity and is not recommended for PCA use.

Dolophine (methadone) is a long-acting opioid, typically not used in PCA pumps due to its longer half-life and risk of prolonged effects.

Summary:

The most appropriate and commonly used medications for PCA pumps are morphine, hydromorphone (Dilaudid), and fentanyl due to their effective pain management properties, safety profile, and predictability when administered through PCA devices.

Correct Answer: Pneumonia.

Pneumonia: After surgery, patients are at an increased risk of retaining pulmonary secretions due to immobility and reduced respiratory effort.

This can lead to the development of atelectasis (collapse of lung tissue) and create an environment conducive to bacterial growth in the lungs, potentially leading to pneumonia.

Deep breathing and coughing exercises help to mobilize secretions, expand the lungs, and reduce the risk of pneumonia.

Why the other options are wrong:

Hypoxemia: While retained secretions can impair oxygen exchange and contribute to hypoxemia, the primary concern when emphasizing deep breathing and coughing is preventing pneumonia, not directly correcting low oxygen levels. Hypoxemia may result from complications like atelectasis, but it is not the most direct result of retained secretions compared to pneumonia.

Fluid imbalance: Retained pulmonary secretions are not directly linked to fluid imbalance. Fluid imbalance usually refers to changes in electrolytes, water retention, or dehydration, which are unrelated to secretions in the lungs.

Pulmonary embolism: A pulmonary embolism (PE) occurs when a blood clot blocks a pulmonary artery, typically due to venous thromboembolism. While post-operative patients are at risk for PE, the primary concern with retained secretions is preventing pneumonia rather than embolism. Deep breathing and coughing help promote lung expansion, but do not directly prevent a pulmonary embolism.

Summary:

Retained pulmonary secretions after surgery increase the risk of pneumonia by promoting bacterial growth in the lungs. Deep breathing and coughing exercises help prevent this complication by improving lung ventilation, mobilizing secretions, and reducing the risk of infection.

Correct Answers are 

WBC 14,200 mm³, 

10% bands, and

Respiratory rate of 30.

A systemic reaction to an infection, especially a surgical infection, involves systemic inflammatory responses that can affect multiple organ systems. These findings are indicative of a systemic response:

WBC 14,200 mm³: A white blood cell (WBC) count of 14,200/mm³ is elevated, which suggests the body is mounting an immune response to infection. An increased WBC count is a common sign of systemic infection.

10% bands: The presence of bands (immature white blood cells) indicates that the body is in a state of acute infection and is actively producing and releasing new white blood cells to fight the infection. A left shift in the WBC differential (increased bands) is indicative of a systemic inflammatory response.

Respiratory rate of 30: A respiratory rate of 30 is elevated and suggests that the patient may be experiencing a systemic response to infection or sepsis, as an increased respiratory rate is a compensatory mechanism to improve oxygen delivery during times of stress or infection.

Why the other options are wrong:

Pain at the surgical site: Pain at the surgical site is a localized finding related to the surgical procedure and not indicative of a systemic reaction. While pain can be a sign of infection, it is not specific to a systemic inflammatory response.

Erythema: Erythema (redness) at the surgical site is a local sign of inflammation. While it suggests infection at the surgical site, it is not a sign of a systemic reaction. Systemic reactions would be reflected in signs like changes in vital signs, WBC count, and other systemic symptoms.

Summary:

Systemic reactions to infection can manifest through elevated WBC count, bands, and changes in vital signs like respiratory rate. Local symptoms like pain and erythema are more specific to the site of infection but do not indicate a systemic response.

Correct Answer: Leg edema, severe pain from swelling and erythema

Local inflammation typically involves the body's response to injury, infection, or irritation, resulting in the classic signs of redness (erythema), heat, swelling (edema), and pain.

The symptoms in option B, including leg edema, severe pain, and erythema, are indicative of local inflammation.

Leg edema: Swelling occurs due to fluid accumulation from increased vascular permeability during inflammation.

Severe pain: Pain is a hallmark of inflammation, often due to pressure from the swelling or the release of inflammatory mediators.

Erythema (redness): Increased blood flow to the affected area causes redness, which is a common sign of local inflammation.

Why the Other Options Are Incorrect:

Leg edema, tachycardia, leg cool to touch:

While leg edema is present, tachycardia and coolness to touch suggest systemic involvement (such as shock or a circulatory problem) rather than local inflammation. Inflammation would more likely cause warmth, not coolness.

Increased HR, hypotension, cold-moist skin:

These signs are more indicative of systemic issues, such as sepsis or shock, rather than localized inflammation. Local inflammation doesn't typically cause systemic symptoms like increased heart rate, hypotension, or cold skin.

T 101.8, diaphoresis, HR 120:

These symptoms suggest fever and systemic infection, not localized inflammation. The fever and elevated HR are more likely signs of systemic infection, such as sepsis, which involves the whole body, not just a localized area.

Summary:

Local inflammation is most accurately identified by signs like edema, pain, and erythema in the affected area, as described in option B.

Correct Answer: Contact the next of kin

The first step after a patient’s death, following unsuccessful resuscitation efforts, is to inform the next of kin or the designated family members.

This ensures that the family is notified of the death as soon as possible and can begin to process the situation.

This is a compassionate and respectful action, as family members often need emotional support during such difficult times.

Why the Other Options Are Wrong:

Document the time of death

While it is essential to document the time of death, this step comes after notifying the next of kin. The family should be informed before any documentation is completed. Documentation typically includes the time of death, the efforts made during resuscitation, and the physician's certification of death. However, communication with the family is the priority.

Notify the funeral home

Notifying the funeral home is a necessary step but it should be done after informing the next of kin. The family should be the first to be notified about the death, as this involves their personal and emotional needs. The funeral home can only be contacted once the family has been informed and the appropriate procedures are in place.

Contact the orderly for transport to the morgue

Transporting the body to the morgue is important, but it should not occur until the family has been informed and all necessary protocols have been followed. The family should be given the opportunity to see the patient and spend time with them if desired, before any arrangements for transport are made.

Summary:

In the unfortunate event of a patient’s death after unsuccessful resuscitation, the first priority is to contact the next of kin. After this, documentation, notification of the funeral home, and transport arrangements to the morgue can proceed. Communicating with the family with empathy and respect is key during this challenging moment.

Correct Answer: Notify the physician and anticipate a bolus of fluids

A urine output of 10 mL per hour is below the normal range (generally, normal urine output is 30 mL/hour or more for an adult). A urine output lower than 30 mL/hour, particularly in a postoperative patient with a Foley catheter in place, suggests possible renal hypoperfusion, fluid imbalance, or acute kidney injury.

The first step should be to notify the physician, as they will need to evaluate the patient's condition and determine the next steps.

A fluid bolus may be anticipated to increase renal perfusion and improve urine output, particularly if hypovolemia (low blood volume) is suspected.

Why the Other Options Are Less Appropriate:

Irrigate the Foley with 30 mL normal saline:

If the Foley catheter tubing is patent, irrigation is not immediately necessary. Irrigating the catheter is typically done when there is an obstruction or when clots are suspected, but there is no indication that this is the issue based on the information provided. Therefore, this would not be the first step.

Decrease the IV fluid rate and massage the patient's abdomen:

Decreasing the IV fluid rate is not appropriate in a postoperative patient with low urine output, as it may worsen the problem if the patient is hypovolemic. Massaging the abdomen is not an evidence-based approach to managing low urine output and might not address the underlying issue.

Have the patient sit in high-Fowler's position:

While positioning can sometimes influence urinary flow, sitting the patient in a high-Fowler's position is unlikely to have a significant effect on improving urine output in this situation. The underlying cause (e.g., hypoperfusion or fluid imbalance) needs to be addressed first.

Summary:

The most appropriate response is to notify the physician and anticipate a fluid bolus to assess and correct any fluid imbalances that could be affecting renal function.