Nursing Care for Transfusion Reactions
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Questions and Answers

What is the priority action for a client experiencing a possible transfusion reaction?

  • Prepare for resuscitation.
  • Discontinue the transfusion. (correct)
  • Contact the physician for further orders.
  • Slow the rate of the transfusion.
  • When would the nurse contact the physician after discontinuing a transfusion due to a possible reaction?

  • Immediately after stopping the transfusion.
  • After preparing for resuscitation.
  • After assessing the client's vital signs and symptoms. (correct)
  • After slowing the rate of the transfusion.
  • Why is slowing the rate of the transfusion not recommended in a suspected transfusion reaction?

  • It may lead to delayed recognition of the reaction.
  • It may increase the severity of the reaction. (correct)
  • It may increase the risk of fluid overload.
  • It does not allow sufficient time to assess the client.
  • What is the normal hourly urine output for an adult client in ml/kg?

    <p>0.5 ml/kg (A)</p> Signup and view all the answers

    A client weighing 70 kg is receiving IV fluids for dehydration. What minimum hourly urine output would indicate successful rehydration?

    <p>35 mL (B)</p> Signup and view all the answers

    What is the most likely reason for a client presenting to the Emergency Department with vomiting and diarrhea for 4 days?

    <p>Viral infection (C)</p> Signup and view all the answers

    Which assessment finding would be most concerning for a client with prolonged vomiting and diarrhea?

    <p>Decreased urine output (C)</p> Signup and view all the answers

    Why is it important to monitor intravenous fluids and urine output for a client with vomiting and diarrhea?

    <p>To monitor for potential electrolyte imbalances (D)</p> Signup and view all the answers

    What method may be used for fluid delivery, especially among older adults, when oral fluids are insufficient?

    <p>Hypodermoclysis (D)</p> Signup and view all the answers

    Which of the following medications is used to reduce fluid volume excess?

    <p>Diuretics (D)</p> Signup and view all the answers

    Why is potassium chloride administered to clients experiencing vomiting?

    <p>It regulates muscle contraction and relaxation. (C)</p> Signup and view all the answers

    Which electrolyte is primarily responsible for regulating water balance in the body?

    <p>Sodium (B)</p> Signup and view all the answers

    What is the main role of potassium in the body?

    <p>Skeletal and cardiac muscle function (A)</p> Signup and view all the answers

    In what situation would intravenous fluids be ordered for a patient?

    <p>In case of fluid volume deficit with insufficient oral intake (A)</p> Signup and view all the answers

    Why are antibiotics not employed in cases of fluid and electrolyte imbalance?

    <p>They only target bacterial infections. (B)</p> Signup and view all the answers

    Which statement about potassium is incorrect?

    <p>It is found in larger amounts in plasma than in cells. (C)</p> Signup and view all the answers

    What could the client's intake of only 2 glasses of water each day indicate?

    <p>A reduction in normal thirst response (D)</p> Signup and view all the answers

    Why is skin turgor considered a poor indicator of fluid balance in older clients?

    <p>Older skin loses elasticity regardless of hydration status (D)</p> Signup and view all the answers

    What can elevated blood pressure indicate in the context of fluid balance?

    <p>Fluid volume overload or sodium sensitivity (B)</p> Signup and view all the answers

    How does body mass index (BMI) within normal limits relate to dehydration?

    <p>It does not contribute to dehydration (D)</p> Signup and view all the answers

    In what way can being overweight or obese relate to hydration status?

    <p>Fat cells do not contribute significantly to hydration (D)</p> Signup and view all the answers

    What does a poor intake of water in older adults often signal?

    <p>Age-related loss of thirst response (A)</p> Signup and view all the answers

    Which physiological change could explain a reduced thirst response in older adults?

    <p>Normal aging affecting hormonal balance (B)</p> Signup and view all the answers

    What significant factor should be considered when assessing hydration in older adults?

    <p>BMI can be a component of dehydration understanding (B)</p> Signup and view all the answers

    Which pediatric clients are at the lowest risk for fluid and electrolyte imbalance?

    <p>Pediatric clients with acute conditions that do not affect the GI or electrolyte systems. (A)</p> Signup and view all the answers

    What condition significantly increases the risk of insensible fluid loss in pediatric clients?

    <p>Tachypnea. (D)</p> Signup and view all the answers

    Which hydration practice is appropriate for children during exercise in the heat?

    <p>Stopping every 15-20 minutes to drink fluids. (D)</p> Signup and view all the answers

    Which statement reflects a common misconception regarding child hydration during exercise?

    <p>Hydration is only necessary at the conclusion of sports activities. (B)</p> Signup and view all the answers

    Which of the following recommendations helps prevent heat-related illnesses in children during exercise?

    <p>Promote wearing lightweight, light-colored clothing. (B)</p> Signup and view all the answers

    What is a recommended combination for replenishing fluids lost during exercise?

    <p>A mixture of water and sports drinks. (A)</p> Signup and view all the answers

    What age group is indicated to have the highest risk for insensible fluid loss?

    <p>Toddlers under 2 years old. (D)</p> Signup and view all the answers

    During what duration should children hydrate while exercising in hot conditions?

    <p>Every 15-20 minutes during activity. (D)</p> Signup and view all the answers

    Which statement best describes the function of the peritoneum in peritoneal dialysis?

    <p>The peritoneum allows water and solutes to move from higher to lower concentration areas. (D)</p> Signup and view all the answers

    What is the main mechanism through which metabolic waste is eliminated during peritoneal dialysis?

    <p>Through a combination of diffusion and ultrafiltration. (C)</p> Signup and view all the answers

    Why might generalized weakness occur in a client with renal failure?

    <p>As a result of the underlying disease process leading to renal failure. (A)</p> Signup and view all the answers

    What is the role of the dialysate in peritoneal dialysis?

    <p>To facilitate the exchange of wastes through osmotic and diffusion processes. (C)</p> Signup and view all the answers

    What could happen if the peritoneum were not semi-permeable?

    <p>Osmosis would not be possible, leading to fluid retention. (C)</p> Signup and view all the answers

    Which statement is incorrect regarding the peritoneum during dialysis?

    <p>The peritoneum acts as a barrier preventing all substances from passing. (A)</p> Signup and view all the answers

    What primarily affects the rate of diffusion in peritoneal dialysis?

    <p>Size and concentration of solutes. (A)</p> Signup and view all the answers

    Which physiological process allows the removal of excess water during peritoneal dialysis?

    <p>Osmosis in conjunction with diffusion. (C)</p> Signup and view all the answers

    Which of the following is NOT a risk factor for fluid volume excess in a client receiving intravenous fluids?

    <p>Liver failure (A)</p> Signup and view all the answers

    The nurse is caring for a client who is experiencing fluid volume deficit post hemodialysis. Which of the following clinical manifestations would the nurse expect to see?

    <p>Tachycardia and pale, cool skin (D)</p> Signup and view all the answers

    What is the primary physiological effect of increased antidiuretic hormone (ADH) and aldosterone levels after surgery?

    <p>Increased sodium and water retention (A)</p> Signup and view all the answers

    What is the rationale for the nursing assessment of the client's skin temperature and color in a client with fluid volume deficit?

    <p>To assess for signs of dehydration (C)</p> Signup and view all the answers

    What is the primary goal of fluid replacement in a client with fluid volume deficit?

    <p>To restore fluid balance and circulating volume (A)</p> Signup and view all the answers

    Which of the following nursing interventions would be MOST appropriate for a client with fluid volume deficit following hemodialysis?

    <p>Administering intravenous fluids (C)</p> Signup and view all the answers

    What is the most common cause of fluid volume excess in postoperative clients?

    <p>Increased ADH and aldosterone levels (C)</p> Signup and view all the answers

    The nurse recognizes that the client's decreased urine output is a sign of fluid volume deficit. Which of the following is the MOST ACCURATE explanation for this finding?

    <p>The kidneys are conserving water to maintain blood volume. (A)</p> Signup and view all the answers

    Flashcards

    Blood transfusion reaction

    An adverse response to a blood transfusion, requiring immediate intervention.

    Priority nursing intervention

    The most important action a nurse must take in a critical situation.

    Intravenous fluid monitoring

    The process of tracking fluids administered through IV to a patient.

    Urine output measurement

    The assessment of the amount of urine produced by a client in an hour.

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    Normal urine output

    Adequate urine output is at least 0.5 mL/kg per hour for adults.

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    Success indicator for rehydration

    A urine output of at least 35 mL per hour is required for adequate rehydration in a 70 kg adult.

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    Collaborative treatment

    The process of working together with physicians to determine patient care.

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    Viral infection

    An illness caused by a virus, often leading to symptoms like diarrhea and vomiting.

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    Intravenous fluids

    Fluids given directly into a vein for hydration when oral intake is insufficient.

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    Hypodermoclysis

    Administration of fluids subcutaneously, often for older adults.

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    Fluid volume deficit

    A reduction in the amount of fluid in the body, leading to dehydration.

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    Diuretics

    Medications that promote the removal of excess fluid from the body.

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    Potassium chloride

    A medication used to replenish potassium, especially after vomiting.

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    Sodium

    An electrolyte that plays a critical role in regulating water balance in the body.

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    Calcium

    A vital mineral that regulates muscle contraction and relaxation.

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    Malnutrition

    A condition resulting from inadequate or imbalanced intake of nutrients.

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    Thirst response

    The body's natural signal to drink water when dehydrated.

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    Skin turgor

    A test for skin elasticity to assess hydration.

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    Elevated blood pressure

    High blood pressure, which can indicate fluid overload or sodium sensitivity.

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    Body Mass Index (BMI)

    A measure to categorize weight status based on height and weight.

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    Dehydration

    A condition resulting from excessive water loss or insufficient water intake.

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    Age-related changes

    Normal physiological changes that occur as a person ages.

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    Fluid volume overload

    A condition where excess fluid accumulates in the body.

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    Sodium sensitivity

    Increased blood pressure in response to sodium intake.

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    Insensible Water Loss

    Fluid loss that occurs without conscious awareness, such as through respiration and skin.

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    Highest Risk Age Group

    Children under 2 years old with conditions increasing fluid loss are at highest risk.

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    Acute Condition

    A sudden onset condition requiring immediate care, like a broken leg.

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    Chronic Condition

    A long-lasting condition that may require ongoing management.

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    Hydration During Exercise

    Children should drink fluids every 15-20 minutes while exercising.

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    Clothing for Heat Exercise

    Light-colored and lightweight clothing is best for exercising in heat.

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    Preventing Heat Illness

    Children should hydrate before, during, and after exercise to avoid heat-related illnesses.

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    Combination Fluid Replacement

    Using a mix of water and sports drinks is best to replenish lost fluids.

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    Fluid volume excess

    An increase of fluid in the circulatory system causing stress to the heart.

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    Antidiuretic hormone (ADH)

    A hormone that helps regulate water balance in the body, often increased in stress.

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    Aldosterone

    A hormone that increases sodium and water retention, affecting blood volume.

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    Tachycardia

    An increased heart rate often resulting from stress or fluid loss.

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    Sodium retention

    The body's process of keeping sodium, often increased by hormones like ADH and aldosterone.

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    Hemodialysis

    A medical process to remove waste from the blood when the kidneys aren't working.

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    Expected outcomes in hemodialysis

    Goals set for a patient to achieve during treatment, such as balanced fluid levels.

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    Bowel sounds in quadrants

    Normal physiological noises made by the intestines during digestion.

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    Generalized weakness

    A reduction in muscle strength, potentially linked to illness.

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    Renal failure

    A condition in which the kidneys fail to adequately filter waste.

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    Peritoneal dialysis

    A procedure that removes waste and excess fluid using the peritoneum.

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    Semipermeable membrane

    A barrier that allows certain substances to pass while blocking others.

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    Diffusion

    Movement of particles from an area of high concentration to low concentration.

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    Osmosis

    The diffusion of water across a semipermeable membrane.

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    Metabolites

    Substances produced during metabolism, usually waste products.

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    Description

    This quiz covers critical nursing actions and assessments related to transfusion reactions, fluid balance, and monitoring for clients with dehydration, vomiting, and diarrhea. Test your knowledge on the appropriate measures and normal physiological responses in these scenarios.

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