Blood Transfusion
What is the absolute first nursing action required across ALL types of acute transfusion reactions when an adverse event is suspected?
STOP the transfusion immediately.
What anatomical space is a chest tube inserted into, and what are the three broad categories of substances it is designed to drain?
Inserted into the pleural space (between the lungs and inner chest wall); designed to drain air, blood, or fluid.
What is the primary complication associated with CVADs, and what acronym is commonly used to describe it?
Infection, commonly referred to as CLABSIs (Central Line-Associated Bloodstream Infections).
What does the acronym 'HAND' represent regarding best practice bundles for preventing catheter-related bloodstream infections (CRBSIs)?
H: Hygiene; A: Antisepsis; N: No-Touch Technique; D: Documentation.
What specific range of negative wall suction pressure (mm Hg) is designated as the appropriate agency limit for an adult patient?
80 to 120 mm Hg for adults.
What specific fluid and type of tubing administration set must be utilized when setting up equipment for a standard blood transfusion?
Y-Type Blood Set (with filter and drip chamber) and a bag of 0.9% Normal Saline.
For patients requiring a chest tube, identify the exact type of fluid or air that accumulates in the pleural space for each of the following medical conditions: Pneumothorax, Hemothorax, Pleural Effusion, Empyema, and Chylothorax.
Pneumothorax = Air; Hemothorax = Blood; Pleural Effusion = Serous Fluid; Empyema = Pus/Infected Fluid; Chylothorax = Chyle/Lymphatic Fluid.
What fundamental "Golden Rule" must nurses remember regarding how pathogens interact with a central venous access device (CVAD) compared to peripheral IV lines?
Any pathogen that enters a central line completely bypasses the body's natural skin barriers and travels directly into the patient's central circulation, severely escalating the risk of a systemic infection.
Within what specific timeframe post-removal does post-infusion phlebitis typically present in a patient?
Generally, it is presented within 48 to 96 hours after the catheter has been removed.
What are the specific parameters (duration and percentage) required for hyperoxygenating a patient before beginning the suction pass?
Pre-oxygenate the patient with 100% oxygen for at least 30 to 60 seconds to prevent profound procedural hypoxia.
By how much should 1 unit of Packed Red Blood Cells (PRBC) expect to raise a patient's Hemoglobin (Hgb) and Hematocrit (Hct) levels?
It should raise Hemoglobin (Hgb) by 1 g/dL and Hematocrit (Hct) by 3%.
What are the names and primary functions of the three distinct chambers found within a closed-chest drainage unit?
Chamber 1 = Collection Chamber (where fluid drains and is measured); Chamber 2 = Water Seal (acts as a one-way valve with at least 2cm of water preventing air reentry); Chamber 3 = Suction Control (regulates the applied suction, typically -20 cm H2O).
Central line dressing changes fall under which technique phase: Clean or Sterile?
Sterile Technique (Zero germs phase).
What is the core clinical difference between intravenous infiltration and intravenous extravasation?
Infiltration is the leakage of a non-vesicant IV solution or medication into extravascular tissue. Extravasation is the leakage of a vesicant solution or medication, which can cause severe blistering, deep tissue damage, necrosis, and sloughing.
According to the Nursing Safety Priority Action Alert, how must suction application differ when inserting a tracheostomy catheter compared to withdrawing it?
Insertion phase: Suction must never be applied while inserting the catheter to prevent mucosal trauma and severe hypoxia.
Withdrawal phase: Suction must be applied continuously during catheter withdrawal to effectively clear secretions and prevent them from dropping back into the lower airway.
What is the operational difference between a 'Type and Screen' order and a 'Type and Crossmatch' order?
A 'Type and Screen' only screens the recipient's blood for type, Rh factor, and known antibodies. A 'Type and Crossmatch' physically matches the recipient's blood to the donor's blood to confirm absolute compatibility.
What does the term 'tidaling' mean in Chamber 2, and what does its presence indicate?
Tidaling is the normal rising and falling of the water level with the patient's respirations. It indicates that the system is patent and responding to intrapleural pressure changes.
What are the two most ideal patient positions during central line cap changes to reduce the risk of air embolism?
Flat or slight Trendelenburg position.
What are the immediate step-by-step nursing interventions required to manage a localized IV site hematoma?
Remove the IV catheter, apply direct pressure until bleeding stops completely, apply a cold compress for the first 24 hours, and follow with warm compresses to facilitate reabsorption of the hematoma.
When setting up the sterile suction field, how does the nurse assign and utilize their hands to maintain strict aseptic technique?
The nurse designates one hand as the sterile hand (used exclusively to handle the sterile catheter and touch the sterile field) and one hand as the non-sterile hand (used to handle non-sterile equipment like the wall suction control and hyperoxygenation button).
What are the classic hallmark symptoms of an Acute Hemolytic Reaction caused by ABO incompatibility?
Flank/lumbar pain, fever, chills, hypotension, tachycardia, uncontrollable bleeding, and hemoglobinuria.
In a dry suction chest drainage system, how is the prescribed amount of suction regulated and determined, and why does increasing the wall suction regulator not increase the suction delivered to the patient?
The amount of suction is determined and regulated solely by the built-in rotary dial on the chest drainage unit itself (typically set to -20 cm H2O), which controls an internal mechanical regulator.
During a central line (CVAD) dressing change, how do the removal of the old dressing and the application of the new dressing differ regarding the use of clean versus sterile technique?
How does the immediate treatment of phlebitis occurring in the first week of a PICC line insertion uniquely differ from a standard peripheral IV (short PIVC)?
A short PIVC must be removed immediately at the first sign of phlebitis. In contrast, phlebitis occurring in the first week of a PICC line may be treated without removal by applying continuous heat, resting, and elevating the extremity.
Why is a cuffed tracheostomy tube specifically indicated for patients who are receiving mechanical ventilation?
A cuffed tube ensures that the air delivered by the mechanical ventilator flows directly into the lungs without leaking around the tube, maintaining appropriate tidal volumes and ventilation pressures.