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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