To measure the temp for the tympanic membrane, what should the nurse do?
Pull the Pinna back and upward
True or false. A patient that had a masectomy two years ago would affect her vital signs
True
True or faulse. A patient reporting a stuffy nose would affect vital signs?
True
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
True or false. The patient that has been fasting for blood test would affect how you would take thier vital signs.
False.
True or false. A patient taking Lanoxin would affect the way you would assess their vital signs?
True.
True of False. A pt who is 60 lbs overweight would affect the way you would assess the person's vital signs.
True
When assessing a pt's respiration in bed, the bed should be elevated how much?
45-60 degrees
Where is the point of maximal impulse located?
at the 5th intercostal space, left to the midclavicular line
The difference between a pt's systolic and diastolic pulse pressure is called what?
Pulse pressure
What is the best way to determine a pt's depth of respiration?
observe the degree of chest movement upon insp and exp.
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
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
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
When taking a pt's temp orally, where do you place the covered probe?
In the posterior lingual pocket, lateral to the midline
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
What is the tranfusion of the pt's own blood?
Autologous transfusion
True of False. A Jehova's Witness is most likey to agree to autologous transfusion.
True
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.
What are some subjective signs that a person is having an adverse reaction to a blood transfusion?
Chills, nausea, chest pain, backache, muscle pain
what is an essential action prior to starting a blood transfusion?
Ensure informed consent has been obtained
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?
Antibody
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
Antigen
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
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
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
This type of infusion reaction's symptoms include flushing, hives, itching, and wheezing.
Allergic
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
What type of blood contains no antigens at all?
Type O
What type of blood is known as the universal donor?
Type O
What is in the transfused blood that trigger hemolytic reactions to non compatible blood?
Specific antigens
why can a person with type A blood recieve blood from a person with type O blood?
Type O blood contains no A antigens
True of false. Ther are no O Antibodies in any type of blood.
True
True of False. Type O blood contains A and B antibodies.
True
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.
What hemoglobin level is required for an autologuous donation?
11g/dl
what is it called when their is a response to another person's antigents?
Alloimmunization
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
Which component of blood transports waste products to the kidneys and liver?
Plasma
A platlelet transfusion is indicated for a patient who has what?
Thrombocytopenia
What is a low platelet count?
Thrombocytopenia.
how is a pt with a hemolytic anemia, or sickle cell anemia treated?
RBC transfusion
When administering a transfusion of packed blood cells, how long should the unit be allowed to be transfused?
Within 4 hours
for the first 15 minutes of an infusion, what rate should the blood be infused at?
