A bloody nightmare💉
A nurse is caring for a patient receiving a blood transfusion. Ten minutes later after starting the infusion, the patient reports chills, back pain, and feels anxious. What is the nurse's priority action?
What is stop the transfusion immediately and infuse normal saline with new tubing?
Rationale:
The priority nursing action when a transfusion reaction is suspected is to stop the transfusion immediately to prevent further infusion of incompatible blood.
The nurse then maintains IV access by infusing 0.9% normal saline through new tubing to prevent any contaminated or incompatible blood from entering the circulation.
After this, the nurse should notify the provider and the blood bank, monitor vital signs, and save the blood bag and tubing for investigation.
This heart sound, heard as "Lub", occurs when the mitral and tricuspid valves close.
What is the S1 heart sound?
Rationale: The S1 heart sound, or the first heart sound, is produced by the simultaneous closing of the Atrioventricular (AV) valves—specifically the mitral (bicuspid) valve on the left side and the tricuspid valve on the right side of the heart.
This type of anemia results from a deficiency of intrinsic factor, which is necessary for the absorption of vitamin B12
What is pernicious anemia?
Peritonitis
A nurse is assessing a client receiving peritoneal dialysis who reports fever and severe abdominal pain. The nurse notes a rigid, board-like abdomen. What should the nurse suspect?
Rationale: Peritonitis is an infection of the peritoneum and a life-threatening complication of peritoneal dialysis. Signs include fever, abdominal pain, board-like abdomen, nausea, and changes in bowel habits.
What complication is this?
A client develops chills, fever, low back pain, and hypotension within minutes of a blood transfusion.
What is an acute hemolytic transfusion reaction?
Rationale:
This occurs when the donor’s blood is incompatible with the client’s ABO or Rh type. The body attacks the transfused RBCs, causing them to lyse.
A whooshing sound that indicates turbulent blood flow through heart valves.
What is a murmur?
rationale:A heart murmur is an unusual sound heard during a heartbeat, typically described as a whooshing or swishing sound. It is caused by turbulent (non-laminar) blood flow through the heart due to damaged or narrowed heart valves (stenosis) or valves that do not close completely (regurgitation/insufficiency), allowing blood to flow backward.
This form of anemia results from bone marrow failure and leads to pancytopenia, increasing the risk of infection, bleeding, and fatigue.
What is aplastic anemia?
Rationale: Aplastic anemia involves suppression or destruction of bone marrow stem cells, leading to decreased production of all blood cells: RBCs, WBCs, and platelets.
Answer:
C -"It may take several months to a year for my kidneys to fully recover."
A nurse is teaching a client recovering from AKI about the recovery phase. Which statement by the client indicates understanding of this phase?
A- "My kidney function should return to normal in a few days."
B- "I might need dialysis for the rest of my life."
C- "It may take several months to a year for my kidneys to fully recover."
D- "I should expect to urinate less during this phase."
Rationale: During the recovery phase, kidney function gradually improves and may take up to a year to return to baseline.
What complication is this?
A client receiving a transfusion suddenly develops dyspnea, crackles, hypertension, and jugular vein distention (JVD).
What is transfusion-associated circulatory overload (TACO)?
Rationale:
This occurs when blood is infused too rapidly, especially in older adults or clients with cardiac compromise. The excess volume leads to cardiogenic pulmonary edema.
This is the definitive treatment for ventricular fibrillation.
What is defibrillation?
Rationale: Defibrillation is the definitive treatment as it delivers an unsynchronized, high-energy electrical shock to stop the chaotic electrical activity, allowing the heart's natural pacemaker to restart with a normal rhythm.
This lab pattern: low serum iron, low ferritin, and high total iron-binding capacity (TIBC) is most indicative of this type of anemia.
What is iron deficiency anemia?
Rationale: In iron deficiency anemia, iron stores (ferritin) are depleted, serum iron is low, and TIBC is elevated as the body tries to bind to more iron.
Abdominal ultrasound or CT scan
A client is suspected of having PKD. Which diagnostic test will the nurse anticipate being ordered to confirm the diagnosis?
A-Electrocardiogram (ECG)
B-Abdominal ultrasound or CT scan
C-Chest x-ray
D-Pulmonary function test
Rationale: PKD is diagnosed using imaging to visualize kidney cysts; the most commonly used are ultrasound, CT, or MRI. Genetic testing and urinalysis can also support the diagnosis.
Which complication should the nurse suspect?
Within 6 hours of transfusion, a client develops acute respiratory distress with hypotension but no signs of fluid overload.
What is transfusion-related acute lung injury (TRALI)?
Rationale:
TRALI is a non-cardiogenic pulmonary edema caused by donor antibodies reacting with recipient leukocytes. It triggers capillary leakage and inflammation.
This procedure uses a direct countershock synchronized to the QRS complex to treat dysrhythmias like atrial fibrillation and ventricular tachycardia with a pulse.
What is cardioversion?
rationale: Cardioversion is an emergency or elective procedure that uses a synchronized electrical shock delivered during the R-wave (QRS complex) on the ECG. This timing prevents the shock from falling during the vulnerable T-wave, which could induce ventricular fibrillation. It is used to convert rapid, unstable rhythms like atrial fibrillation and ventricular tachycardia (V-Tach) with a pulse back to a normal sinus rhythm.
This nursing intervention is critical for a patient with a hemoglobin level of 6.5 g/dL to reduce oxygen demand and support tissue perfusion.
What is administering oxygen therapy and conserving energy?
Rationale: Administering oxygen helps maintain adequate oxygenation, while energy conservation reduces metabolic demand and prevents complications like hypoxia and cardiac strain. Nurses should cluster care, encourage rest, and monitor for signs of decompensation.
Disequilibrium syndrome
A client receiving hemodialysis suddenly develops headache, nausea, vomiting, restlessness, and confusion during the procedure. The nurse recognizes these symptoms as most likely indicating which complication?
Rationale: Disequilibrium syndrome occurs when there is a rapid decrease in BUN and fluid volume, which can lead to cerebral edema. Symptoms include confusion, headache, nausea, vomiting, and/or restlessness.
Which lab values are consistent with DIC? (name at least 3)
Disseminated intravascular coagulation (DIC) is a life-threatening disorder in which the body simultaneously forms clots and breaks them down. DIC increases risk for internal and external bleeding and can cause organ damage from microclots.
What is ?
-Elevated D-dimer, prothrombin time, partial thromboplastin, thrombin time, fibrin split product levels/fibrin degradation levels
-Decreased hemoglobin, platelet levels (thrombocytopenia), fibrinogen levels,
Rationale:
In DIC, widespread clotting consumes clotting factors and platelets, leading to a paradoxical risk of bleeding. Laboratory tests reflect both excessive clot formation and breakdown:
Elevated D-dimer and fibrin degradation products indicate increased fibrinolysis as the body breaks down clots.
Prolonged PT, PTT, and thrombin time show depletion of clotting factors, making the blood slower to clot.
Decreased platelets (thrombocytopenia), hemoglobin, and fibrinogen reflect consumption of these components in microvascular clot formation and ongoing bleeding.
This medication used for SVT can briefly stop the heart, so a nurse should have a defibrillator on hand when administering.
What is adenosine?
Rationale: Adenosine is a rapid-acting drug used to treat Supraventricular Tachycardia (SVT). It works by briefly blocking electrical conduction through the AV node, which effectively causes a transient period of asystole (briefly stopping the heart). Because of this high-risk effect, a patient must be continuously monitored, and a defibrillator/code cart must be immediately available in case the heart does not restart.
A 72-year-old patient with chronic anemia presents with shortness of breath, bilateral leg edema, and crackles on auscultation. This is the nurse’s priority action.
What is notify the healthcare provider of signs of possible heart failure?
Rationale: These symptoms suggest decompensated heart failure, a serious complication of severe anemia. The heart compensates for low oxygen-carrying capacity by increasing cardiac output, which can eventually lead to volume overload and heart failure.
Pre-renal
A nurse is assessing a client admitted with acute kidney injury (AKI). The client reports vomiting and diarrhea, has a blood pressure of 88/56mmHg, dry mucous membranes, and poor skin turgor. Which type of AKI should the nurse suspect?
Rationale: Client is showing signs of hypovolemia, hypotension, dehydration, and poor perfusion, which decreases blood flow to the kidneys. This leads to pre-renal AKI, where the problems happen in the blood flow before reaching the kidneys.