Line of defense
The first line of defense (innate immunity)? Name 3
What is skin, mucosa, cilia
Sunken eyes, furrowed tongue, cracked lips, poor vein filling, and tenting indicate this imbalance.
What is fluid volume deficit (dehydration)?
INS ( nurse) recommends changing IV catheters at this interval.
What is every 72–96 hours?
A PICC with redness, swelling, and drainage requires this priority action.uestion: Then nurse’s priority action
A. Apply a warm compress
B. Continue the infusion and monitor
C. Stop the infusion and notify the provider
D. Flush the line with saline
C.What is stop the infusion and notify the provider?
Rationale: Signs of infection require immediate intervention to prevent sepsis.
Case: A patient is about to receive a unit of packed red blood cells. The nurse selects an IV fluid that is safe to run with blood.
A. 0.9% normal saline
B. 5% dextrose in water
C. Lactated Ringer’s
D. 0.45% saline
What is A normal saline 0.9
This type of fluid loss occurs through the skin and lungs.
What is insensible water loss?
A potassium level of 3.1 mEq/L calls for this treatment.
What is potassium replacement?
The nurse should perform this action first before giving an IV push medication.
Case: While flushing a PICC line, the nurse notes resistance and is unable to draw blood.
Complication is likely occurring
A. Catheter occlusion (thrombotic)
B. Phlebitis
C. Air embolism
D. Infiltration
What is a A catheter occlusion (thrombotic)?
Rationale: A Thrombotic occlusion may require intervention or line replacement.
Case: A patient with AB- blood type requires a transfusion. The nurse identifies compatible donor types.
A. AB-, A-, B-, and O-
B. AB+, AB-, A+, B+
C. O+ only
D. AB+ only
What is Answer: A. AB-, A-, B-, and O-
Rationale: AB- is compatible with all Rh-negative blood types.
This type of immunity develops after exposure to a pathogen or receiving a vaccination.
What is active immunity
Serum potassium below 2.5 or above 7.0 can trigger this life-threatening event.
What is a cardiac arrhythmia?
When inserting an IV in a child, this action comes first.
What is explaining the procedure to gain cooperation?
Case: During central line insertion, the nurse instructs the patient to hold their breath and bear down.
Prevents which complication?
A. Catheter occlusion
B. Air embolism
C. Phlebitis
D. Pneumothorax
What is an A air embolism
Case: Thirty minutes into a transfusion, a patient develops fever, chills, malaise, tachypnea, and hypotension.
Complication should the nurse suspect
A. Sepsis
B. Hyperkalemia
C. Fluid overload
D. Hypoglycemia
A What is sepsis
This type of immunity occurs when antibodies are transferred from one person to another—such as from mother to fetus.
What is Passive Immunity
An infant’s hydration status is best assessed using these measures.
What are wet diapers, fontanel status, tears, mucous membranes, and weight?
This IV complication occurs when fluid leaks into surrounding tissue instead of the vein
What is IV infilatration
Case: A patient undergoing central venous catheter placement suddenly experiences difficulty breathing. A chest X-ray confirms a collapsed lung.
Complication occurred
A. Pneumothorax
B. Air embolism
C. Thrombophlebitis
D. Fluid overload
What is A pneumothorax?
Case: An older adult patient is receiving multiple units of blood. The nurse plans to give a medication between units to prevent fluid overload.
The nurse would give
A. Furosemide
B. Digoxin
C. Mannitol
D. Hydrochlorothiazide
➡️ Answer: A. Furosemide
Rationale: Furosemide prevents transfusion-associated circulatory overload (TACO), especially in older adults.
These are the two major branches of the third line of defense: one involving B-cells and one involving T-cells
DP
Double Jeopardy points
What are humoral immunity and cell-mediated immunity?
This electrolyte is important for nerve and muscle function and is lost in diarrhea and some diuretics, requiring dietary intake from bananas, spinach, and oranges.
DP
What is Potassium
Case: A patient is scheduled for a blood transfusion. The nurse selects tubing that includes a specific filter to remove clots.
Tubing is used for blood transfusions?
A. Standard IV tubing with 15-micron filter
B. Microdrip tubing
C. Y-tubing with a 170–260 micron filter
D. Extension tubing without a filter
What is Y-tubing with a 170–260 micron filter?
Rationale: Y-tubing with the specified filter is standard for safe blood transfusions
A patient receiving PN via a central line develops a sudden fever of 102°F, chills, and hypotension. Which action should the nurse take first?
A. Administer antipyretics
B. Obtain blood cultures
C. Stop the PN infusion
D. Notify the healthcare provider
C stop the infustion
Case: A patient receiving multiple units of packed RBCs develops hypertension, shortness of breath, and distended neck veins. The patient has a history of heart failure.
The most likely complication, and what should the nurse do first
A. Hemolytic reaction; stop the transfusion
B. Transfusion-associated circulatory overload (TACO); slow the transfusion and give diuretics
C. Sepsis; obtain cultures
D. Hyperkalemia; administer calcium gluconatate
Answer: B. Transfusion-associated circulatory overload (TACO); slow the transfusion and give diuretics
Rationale: Older adults or patients with heart failure are at risk for fluid overload during transfusion. Early recognition and intervention prevent worsening respiratory distress.