ATI final 2

  1. The S2 sound is heard when the heart does what?
    the Semilunar valves close
  2. To measure the temp for the tympanic membrane, what should the nurse do?
    Pull the Pinna back and upward
  3. True or false. A patient that had a masectomy two years ago would affect her vital signs
  4. True or faulse. A patient reporting a stuffy nose would affect vital signs?
  5. True of False. A person who is 60 pounds over weight will affect the way you take their vital signs
    True. You will prbo need a bigger than normal cuff
  6. True or false. The patient that has been fasting for blood test would affect how you would take thier vital signs.
  7. True or false. A patient taking Lanoxin would affect the way you would assess their vital signs?
  8. True of False. A pt who is 60 lbs overweight would affect the way you would assess the person's vital signs.
  9. When assessing a pt's respiration in bed, the bed should be elevated how much?
    45-60 degrees
  10. Where is the point of maximal impulse located?
    at the 5th intercostal space, left to the midclavicular line
  11. The difference between a pt's systolic and diastolic pulse pressure is called what?
    Pulse pressure
  12. What is the best way to determine a pt's depth of respiration?
    observe the degree of chest movement upon insp and exp.
  13. When taking a pt temperature rectally, what is important for the nurse to do?
    Insert the probe into the anus about an 1 1/2 inches
  14. you are assessing a pt's temp and it reads 102 degrees F. Out of the following, what would you expect to find
    elevated pulse rate
    decrease pulse rate
    elevated blood pressure
    decreased blood pressure
    Elevated pulse
  15. Why is it important to notice the pressure on the manometer when you hear the fourth Korotkoff sound?
    Because you might hear a 5th Korotkoff sound
  16. When taking a pt's temp orally, where do you place the covered probe?
    In the posterior lingual pocket, lateral to the midline
  17. What procedure will help the nurse protect the pt against the possibility of a blood group imcompatibilty who is about to recieve a unit of blood?
    Compare the ID # on the blood unit with those on the order form and the wristband
  18. What is the tranfusion of the pt's own blood?
    Autologous transfusion
  19. True of False. A Jehova's Witness is most likey to agree to autologous transfusion.
  20. Prior to administering a blood transfusion, it is essential to explain to the paitent that?
    They must immediately reoport any subjective symptoms like chills, nausea, or itching.
  21. What are some subjective signs that a person is having an adverse reaction to a blood transfusion?
    Chills, nausea, chest pain, backache, muscle pain
  22. what is an essential action prior to starting a blood transfusion?
    Ensure informed consent has been obtained
  23. A type of protein the immune system produces to neutralize a threat of some kind, such as an incompatible substance in the blood, is called an?
  24. What is a protein on the surface membrane of rbc's that is capable of inducing specific immune responses and interacting adversely with the products of that response
  25. After a blood transfusion, pt has developed shaking chills, muscle stiffness, and a temp of 101.4. He is flushed and reports headache and "nervousness." What type of transfusion reaction is he most likely experiencing?
    Febrile nonhemolytic
  26. Symptoms of this transfussion reaction include hypotension as well as chills and a fever. Symptoms sometimes develop several hours later after transfusion. Contaminated blood products usualy are the cause
    Septic shock
  27. This type of transfussion reaction is usually immediate and is caused by imcompatibility of donor blood. symptoms include fever, chills, anxiety, nasea, chest tightness, dyspnea, tachycardia, tachypnea, and hypotension.
    Acute Hemolytic shock
  28. This type of infusion reaction's symptoms include flushing, hives, itching, and wheezing.
  29. The most common type of tranfusion reaction. symptoms include fever usually 2 hours after tranfussion as well as chills, headache, flushing, anxiety and muscle pain.
    Febrile Nonhemolytic
  30. What type of blood contains no antigens at all?
    Type O
  31. What type of blood is known as the universal donor?
    Type O
  32. What is in the transfused blood that trigger hemolytic reactions to non compatible blood?
    Specific antigens
  33. why can a person with type A blood recieve blood from a person with type O blood?
    Type O blood contains no A antigens
  34. True of false. Ther are no O Antibodies in any type of blood.
  35. True of False. Type O blood contains A and B antibodies.
  36. True of False. There are O antigens in Type A blood and other types of blood.
    False. there are no O antigens in Type A blood or any other type of blood.
  37. What hemoglobin level is required for an autologuous donation?
  38. what is it called when their is a response to another person's antigents?
  39. True of false. For an autologous reaction, their is a risk for alloimmunization
    False. Its impossible to have an alloimmunization when you are receiving your own blood
  40. Which component of blood transports waste products to the kidneys and liver?
  41. A platlelet transfusion is indicated for a patient who has what?
  42. What is a low platelet count?
  43. how is a pt with a hemolytic anemia, or sickle cell anemia treated?
    RBC transfusion
  44. When administering a transfusion of packed blood cells, how long should the unit be allowed to be transfused?
    Within 4 hours
  45. for the first 15 minutes of an infusion, what rate should the blood be infused at?
Card Set
ATI final 2
ATI Final 2