The nurse is monitoring a patient receiving a blood transfusion. For Which symptoms would the nurse stop the transfusion but NOT administer 0,9% normal saline?

dyspnea, crackles, hypertension, and edema

low back pain, hypotension, and tachycardia

urticaria, itching, wheezing, angioedema

chest tightness, fever, chills/rigors

Answer and Explanation

The Correct Answer is A

A) Dyspnea, crackles, hypertension, and edema:
These symptoms suggest a transfusion-related acute lung injury (TRALI) or circulatory overload (TACO), both of which are potentially life-threatening conditions. In cases of TRALI or TACO, the nurse should stop the transfusion immediately but should NOT administer 0.9% normal saline because saline could exacerbate fluid overload and worsen pulmonary edema. Instead, the nurse should focus on managing respiratory distress, ensuring proper oxygenation, and notifying the healthcare provider for further intervention.

B) Low back pain, hypotension, and tachycardia:
These symptoms are typically indicative of a hemolytic transfusion reaction (HTR), which requires immediate intervention. In this case, the transfusion should be stopped immediately, but the nurse should begin administering 0.9% normal saline to help maintain the patient's blood pressure and promote kidney perfusion to prevent renal damage.

C) Urticaria, itching, wheezing, angioedema:
These symptoms are characteristic of a mild allergic reaction to the blood transfusion. In this case, the nurse should stop the transfusion and administer 0.9% normal saline to maintain the patient’s hydration and blood pressure while managing the allergic reaction. The healthcare provider may order antihistamines or corticosteroids to treat the allergic symptoms.

D) Chest tightness, fever, chills/rigors:
These are common symptoms of a febrile non-hemolytic transfusion reaction (FNHTR), which is generally not life-threatening. The nurse should stop the transfusion but can continue administering 0.9% normal saline to support hydration and circulation. FNHTR is often managed with antipyretics (e.g., acetaminophen) to reduce fever and chills, and the transfusion may be resumed if symptoms resolve

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Correct Answer is ["12"]

Explanation

Given:

Ordered dose of Heparin: 20 units/kg

Patient weight: 132 lbs

Concentration of Heparin: 25,000 units/250 mL (100 units/mL)

Step 1: Convert patient weight from pounds to kilograms:

1 pound (lb) = 0.453592 kilograms (kg)

Patient weight in kg = 132 lbs x 0.453592 kg/lb = 59.87424 kg

Step 2: Calculate the total dose of Heparin:

Total dose (units) = Ordered dose (units/kg) x Patient weight (kg)

Total dose (units) = 20 units/kg x 59.87424 kg

Total dose (units) = 1197.4848 units

Step 3: Calculate the volume to be administered:

Volume (mL) = Total dose (units) / Concentration (units/mL)

Volume (mL) = 1197.4848 units / 100 units/mL

Volume (mL) = 11.974848 mL

Step 4: Round to the nearest whole number:

Volume (mL) ≈ 12 mL

A. includes the head-to-toe anterior and posterior assessment B. focuses on the ABCDE's to identify life threating problems C. includes the use of a standard pain scale and past medical/surgical history D. consists of analyzing the results of the diagnostic testing

Correct Answer is B

Explanation

A) Includes the head-to-toe anterior and posterior assessment:
While a head-to-toe physical assessment is important in trauma care, it is not the first priority. The primary assessment focuses on immediate life-threatening conditions, and the head-to-toe assessment would come after the initial stabilization of the patient's airway, breathing, circulation, and disability. A comprehensive physical examination is crucial but secondary to addressing urgent life threats.

B) Focuses on the ABCDE's to identify life-threatening problems:
The ABCDE's (Airway, Breathing, Circulation, Disability, Exposure) are the primary framework for assessing and stabilizing a trauma patient. This approach is used to identify and prioritize life-threatening problems. It ensures that the most critical issues, such as airway obstruction, respiratory failure, shock, and neurological deficits, are addressed first. This protocol is the gold standard in trauma care and is the most appropriate initial assessment in major trauma.

C) Includes the use of a standard pain scale and past medical/surgical history:
While it is important to assess pain and gather a medical history in the trauma patient, these are secondary considerations after addressing immediate threats to life. Pain management and obtaining a full history are crucial, but they are not as urgent as addressing airway, breathing, and circulation issues. These should be part of a more detailed secondary assessment once the patient is stable.

D) Consists of analyzing the results of the diagnostic testing:
Diagnostic testing, such as imaging studies and lab work, are important but are not the first priority. The primary assessment should focus on the ABCDE's. Diagnostic results are typically analyzed after the patient is stabilized, as they provide additional information but do not address immediate survival needs.

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The nurse is monitoring a patient receiving a blood transfusion. For Which symptoms would the nurse stop the transfusion but NOT administer 0,9% normal saline?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A patient is to receive a bolus of Heparin 20 units/kg. The patient weighs 132 lbs. The medication is supplied as 25,000 units/250 mL. How many mL will the nurse give? (round to the nearest whole number)

Correct Answer is ["12"]

Explanation

The nurse understands the primary assessment for a patient following a major trauma:

Correct Answer is B

Explanation

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