Saturday, May 4, 2013

Accident and Emergency Questions


EMERGENCY QUESTION FROM NCLEX

11. A patient arrives at the emergency department complaining of mid-sternal chest pain. Which of the following nursing action should take priority?
A.      A complete history with emphasis on preceding events. 
B.      An electrocardiogram.
C.      Careful assessment of vital signs.
D.      Chest exam with auscultation.

22.  Patient has been hospitalized with pneumonia and is about to be discharged. A nurse  provides discharge instructions to a patient and his family. Which misunderstanding by the family indicates the need for more detailed information?
A. The patient may resume normal home activities as tolerated but should avoid     physical exertion and get adequate rest.
B.   The patient should resume a normal diet with emphasis on nutritious, healthy foods. 
C. The patient may discontinue the prescribed course of oral antibiotics once the symptoms have completely resolved.
D.  The patient should continue use of the incentive spirometer to keep airways open and free of secretions.

33. A nurse is caring for an elderly Vietnamese patient in the terminal stages of lung cancer. Many family members are in the room around the clock performing unusual rituals and bringing ethnic foods. Which of the following actions should the nurse take?
A.  Restrict visiting hours and ask the family to limit visitors to two at a time. 
B.  Notify visitors with a sign on the door that the patient is limited to clear fluids only with no solid food allowed. 
C.  If possible, keep the other bed in the room unassigned to provide privacy and comfort to the family.
D.    Contact the physician to report the unusual rituals and activities.

44. The charge nurse on the cardiac unit is planning assignments for the day. Which of the following is the most appropriate assignment for the float nurse that has been reassigned from labor and delivery?
A. A one-week postoperative coronary bypass patient, who is being evaluated for placement of a pacemaker prior to discharge. 
B. A suspected myocardial infarction patient on telemetry, just admitted from the Emergency Department and scheduled for an angiogram. 
C.  A patient with unstable angina being closely monitored for pain and medication titration.
D.   A post-operative valve replacement patient who was recently admitted to the unit because all surgical beds were filled.

55. A newly diagnosed 8-year-old child with type I diabetes mellitus and his mother are receiving diabetes education prior to discharge. The physician has prescribed Glucagon for emergency use. The mother asks the purpose of this medication. Which of the following statements by the nurse is correct?
A.  Glucagon enhances the effect of insulin in case the blood sugar remains high one hour after injection.
B.   Glucagon treats hypoglycemia resulting from insulin overdose.
C.   Glucagon treats lipoatrophy from insulin injections.
D.   Glucagon prolongs the effect of insulin, allowing fewer injections.

66.  A patient on the cardiac telemetry unit unexpectedly goes into ventricular fibrillation. The advanced cardiac life support team prepares to defibrillate. Which of the following choices indicates the correct placement of the conductive gel pads?
A.      The left clavicle and right lower sternum.
B.       Right of midline below the bottom rib and the left shoulder. 
C.       The upper and lower halves of the sternum. 
D.       The right side of the sternum just below the clavicle and left of the precordium.

77. The nurse performs an initial abdominal assessment on a patient newly admitted for abdominal pain. The nurse hears what she describes as "clicks and gurgles in all four quadrants" as well as "swishing or buzzing sound heard in one or two quadrants." Which of the following statements is correct?
A.  The frequency and intensity of bowel sounds varies depending on the phase of digestion. 
B.  In the presence of intestinal obstruction, bowel sounds will be louder and higher pitched.
C.    A swishing or buzzing sound may represent the turbulent blood flow of a bruit and is not normal.
D.    All of the above.

78. A patient arrives in the emergency department and reports splashing concentrated household cleaner in his eye. Which of the following nursing actions is a priority?
A.      Irrigate the eye repeatedly with normal saline solution. 
B.      Place fluorescein drops in the eye.
C.      Patch the eye.
D.      Test visual acuity.


99. A nurse is caring for a patient who has had hip replacement. The nurse should be most concerned about which of the following findings?
A.      Complaints of pain during repositioning.
B.      Scant bloody discharge on the surgical dressing. 
C.      Complaints of pain following physical therapy. 
D.      Temperature of 101.8 F (38.7 C).

10. A child is admitted to the hospital with an uncontrolled seizure disorder. The admitting physician writes orders for actions to be taken in the event of a seizure. Which of the following actions would NOT be included?
A.      Notify the physician.
B.      Restrain the patient's limbs.
C.      Position the patient on his/her side with the head flexed forward.
D.      Administer rectal diazepam.

11.   Emergency department triage is an important nursing function. A nurse working the evening shift is presented with four patients at the same time. Which of the following patients should be assigned the highest priority?
A.      A patient with low-grade fever, headache, and myalgias for the past 72 hours.
B.       A patient who is unable to bear weight on the left foot, with swelling and bruising following a running accident.
C.       A patient with abdominal and chest pain following a large, spicy meal.
D.      A child with a one-inch bleeding laceration on the chin but otherwise well after falling while jumping on his bed.

12.   A patient is admitted to the hospital with a calcium level of 6.0 mg/dL. Which of the following symptoms would you NOT expect to see in this patient?
A.      Numbness in hands and feet.
B.      Muscle cramping.
C.      Hypoactive bowel sounds.
D.      Positive Chvostek's sign.

13.   A nurse cares for a patient who has a nasogastric tube attached to low suction because of a suspected bowel obstruction. Which of the following arterial blood gas results might be expected in this patient?
A.      pH 7.52, PCO2 54 mm Hg.
B.      pH 7.42, PCO2 40 mm Hg.
C.      pH 7.25, PCO2 25 mm Hg.
D.      pH 7.38, PCO2 36 mm Hg.



14.   A patient is admitted to the hospital for routine elective surgery. Included in the list of current medications is Coumadin (warfarin) at a high dose. Concerned about the possible effects of the drug, particularly in a patient scheduled for surgery, the nurse anticipates which of the following actions?
A.      Draw a blood sample for prothrombin (PT) and international normalized ratio (INR) level.
B.      Administer vitamin K. 
C.      Draw a blood sample for type and crossmatch and request blood from the blood bank.
D.      Cancel the surgery after the patient reports stopping the Coumadin one week previously.

15.   The follow lab results are received for a patient. Which of the following results are abnormal? Note: More than one answer may be correct.
A.      Hemoglobin 10.4 g/dL.
B.      Total cholesterol 340 mg/dL.
C.      Total serum protein 7.0 g/dL.
D.      Glycosylated hemoglobin A1C 5.4%.

16.   A nurse is performing routine assessment of an IV site in a patient receiving both IV fluids and medications through the line. Which of the following would indicate the need for discontinuation of the IV line as the next nursing action?
A.      The patient complains of pain on movement.
B.      The area proximal to the insertion site is reddened, warm, and painful.
C.      The IV solution is infusing too slowly, particularly when the limb is elevated.
D.      A hematoma is visible in the area of the IV insertion site.

17.   A hospitalized patient has received transfusions of 2 units of blood over the past few hours. A nurse enters the room to find the patient sitting up in bed, dyspneic and uncomfortable. On assessment, crackles are heard in the bases of both lungs, probably indicating that the patient is experiencing a complication of transfusion. Which of the following complications is most likely the cause of the patient's symptoms?
A.      Febrile non-hemolytic reaction.
B.      Allergic transfusion reaction.
C.      Acute hemolytic reaction.
D.      Fluid overload.






18.   A patient in labor and delivery has just received an amniotomy. Which of the following is correct? Note: More than one answer may be correct.
A.      Frequent checks for cervical dilation will be needed after the procedure.
B.      Contractions may rapidly become stronger and closer together after the procedure.
C.      The FHR (fetal heart rate) will be followed closely after the procedure due to the possibility of cord compression.
D.      The procedure is usually painless and is followed by a gush of amniotic fluid.

19.   A nurse is counseling the mother of a newborn infant with hyperbilirubinemia. Which of the following instructions by the nurse is NOT correct?
A.      Continue to breastfeed frequently, at least every 2-4 hours.
B.      Follow up with the infant's physician within 72 hours of discharge for a recheck of the serum bilirubin and exam.
C.      Watch for signs of dehydration, including decreased urinary output and changes in skin turgor.
D.      Keep the baby quiet and swaddled, and place the bassinet in a dimly lit area.

20.   A nurse is giving discharge instructions to the parents of a healthy newborn. Which of the following instructions should the nurse provide regarding car safety and the trip home from the hospital?
A.      The infant should be restrained in an infant car seat, properly secured in the back seat in a rear-facing position.
B.      The infant should be restrained in an infant car seat, properly secured in the front passenger seat.
C.      The infant should be restrained in an infant car seat facing forward or rearward in the back seat.
D.      For the trip home from the hospital, the parent may sit in the back seat and hold the newborn.
21.   Rhea, confused and short breath, is brought to the emergency department by a family member. The medical history reveals chronic bronchitis and hypertension. To learn more about the current respiratory problem, the doctor orders a chest x-ray and arterial blood gas (ABG) analysis. When reviewing the ABG report, the nurses sees many abbreviations. What does a lowercase “a” in ABG value present?
A.      Acid-base balance
B.      Arterial Blood
C.      Arterial oxygen saturation
D.      Alveoli



22.   An emergency room nurse is assessing a male client who has sustained a blunt injury to the chest wall. Which of these signs would indicate the presence of a pneumothorax in this client?
A.      A low respiratory rate
B.      Diminished breath sounds
C.      The presence of a barrel chest
D.      A sucking sound at the site of injury

23.   A black client with asthma seeks emergency care for acute respiratory distress. Because of this client’s dark skin, the nurse should assess for cyanosis by inspecting the:
A.      Lips.
B.      Mucous membranes.
C.      Nail beds.
D.      Earlobes.

24.   At 11 p.m., a male client is admitted to the emergency department. He has a respiratory rate of 44 breaths/minute. He’s anxious, and wheezes are audible. The client is immediately given oxygen by face mask and methylprednisolone (Depo-medrol) I.V. At 11:30 p.m., the client’s arterial blood oxygen saturation is 86% and he’s still wheezing. The nurse should plan to administer:
A.      Alprazolam (Xanax).
B.      Propranolol (Inderal)
C.      Morphine.
D.      Albuterol (Proventil).

25.   A client is admitted to the emergency department following an overdose of barbiturates. What should the nurse do first?
A.      Assess and assist ventilation.
B.      Monitor the BP.
C.      Prepare to administer blood products.
D.      Place the client in the trendelenburg position.

26.   A male client who is 76 years of age comes to the emergency department with sudden onset of severe pain in his back, flank and abdomen. He reports feeling weak and his BP is 68/31 mmhg. Urine output is absent. Bilateral leg pulses are weak, although bruit and pulsation are noted at the umbilicus. The nurse should first:
A.      Obtain consent for emergency surgery.
B.      Assess leg pulses with a Doppler test.
C.      Palpate the abdomen for presence of a mass.
D.      Start an IV infusion.



27.   An alert client is admitted to the emergency department with a severe laceration of his arm with heavy bleeding. What action should the nurse take first?
A.      Apply a tourniquet above the wound.
B.      Assess pulse and nerve functioning of the arm.
C.      Cover the wound with a dressing and apply firm pressure.
D.      Start an IV infusion.
28.   A small airplane has crashed in a neighbourhood of 10 houses. One of the victims appears to have a cervical spine injury. First aid for this victim includes which of the following?
A.      Establish an airway with head tilt.
B.      Immobilize the spine.
C.      Logroll the victim to a side-lying position.
D.      Elevate the feet 6 inches.

29.   Several clients come to the emergency department suspected contamination by the Ebola virus. The nurse should do which of the following? Select all that apply.
A.       Call in extra staff to assist with the possibility more clients with the same condition.
B.      Isolate all the suspected clients in the emergency department in one area.
C.      Obtain diluted household bleach from housekeeping services.
D.      Restrict visitors from the emergency department.
E.       Request that the emergency department be closed to other client.

30.   The nurse in the immediate care clinic is assessing a client who is 80 years of age and lives with his son’s family. The client is scald burns on his hands and both foramens (10% first-degree burns). The nurse should do first:
A.      Cleanse the wounds with warm water.
B.      Apply antibiotic cream.
C.      Call for transport to a burn centre.
D.      Cover all the burns with sterile dressing.

31.   A client who is 16 years of age is seen in an emergency department following the rape. The management of a rape victim should primarily be directed toward:
A.      Relieving physical discomfort.
B.      Maintain self-esteem.
C.      Assessing for sources of infection resulting from the rape.
D.      Teaching the victim how to prevent future attacks.





A nurse who witnesses a motor vehicle accident stops to provide emergency assistance to the injured motorists.

32.   When the nurses assess a victim who has been thrown from the vehicle, which assessment finding is most suggestive of the serious head injury?
A.      The victim has a bad head injury.
B.      The victim asks the nurse, “What happened?”
C.      The victim is hesitant to move.
D.      The client has clear fluid draining from the ears.


The accidents victim is taken to the emergency department for evaluation.

33.   While waiting for the physician to examine the client, how should the nurse position the client?
A.      Dorsal recumbent with the legs elevated.
B.      Supine with head slightly elevated.
C.      Flat with neck immobilizer in place.
D.      Right lateral with the neck flexed.

Sunday, March 10, 2013

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Wednesday, March 6, 2013

TRANSFUSI DARAH

ISTILAH DALAM TRANSFUSI DARAH:

  1. Transfusi = proses pemindahan darah
  2. Donor = orang yang memberikan sejumlah darah ke orang lain yang membutuhkan
  3. Resipien = orang yang menerima sejumlah darah dari orang lain
  4. Donor Universal = golongan darah yang bisa memberikan sejumlah darahnya ke semua golongan darah lain. Golongan darah yang dimaksud adalah O
  5. Resipien Universal = Golongan darah yang dapat menerima sejumlah darah dari semua golongan darah lain. Golongan darah yang dimaksud adalah AB
  6. Serum = plasma tanpa fibrinogen
  7. Antigen = aglutinogen merupakan protein asing yang akan digumpalkan oleh antibodi / aglutinin
  8. Antibodi = protein plasma yang dapat menggumpalkan antigen / aglutinin
  9. Aglutinasi = penggumpalan darah akibat ketidakcocokan antara jenis aglutinogen donor dengan aglutinin resipien

Pengertian Transfusi Darah

  • Transfusi Darah adalah proses pemindahan darah dari donor yang sehat kepada penderita (recipient).

TUJUAN TRANSFUSI DARAH
  1. Meningkatkan volume sirkulasi darah setelah pembedahan, trauma atau perdarahan
  2. Meningkatkan jumlah sel darah merah dan untuk mempertahankan kadar hemoglobin pada klien yang mengalami anemia berat.
  3. Memberikan komponen seluler yang terpilih sebagai terapi pengganti (misal : faktor pembekuan plasma untuk membantu mengontrol perdarahan pada klien yang menderita hemofilia)

INDIKASI TRANSFUSI DARAH

  • Pasien dengan kehilangan darah dalam jumlah besar (operasi besar, perdarahan postpartum, kecelakaan, luka bakar hebat, penyakit kekurangan kadar Hb)
  • Pasien anemia berat,
  • Kelaian darah bawaan, pasien yang mengalami penyakit liver ataupun penyakit lainnya yang mengakibatkan tubuh pasien tidak dapat memproduksi darah atau komponen darah sebagaimana mestinya.


Jenis Donor Darah
}  Ada dua macam donor darah yaitu :
  1. Donor keluarga atau Donor Pengganti adalah darah yang dibutuhkan pasien dicukupi oleh donor dari keluarga atau kerabat pasien.
  2. Donor Sukarela adalah orang yang memberikan darah, plasma atau komponen darah lainnya atas kerelaan mereka sendiri dan tidak menerima uang atau bentuk pembayaran lainnya. Motivasi utama mereka adalah membantu penerima darah yang tidak mereka kenal dan tidak untuk menerima sesuatu keuntungan.

GOLONGAN
SEL DARAH MERAH
PLASMA
A
Antigen A
Antibodi A
B
Antigen B
Antibodi B
AB
Antigen A & B
Tidak ada Antibodi
O
Tidak ada antigen
Antibodi Anti A &
Anti B

Dua jenis penggolongan darah yang paling penting, yaitu penggolongan ABO dan Rhesus (faktor Rh).

Tabel Kecocokan Plasma


Golongan
Darah
Antigen pada
Eritrosit
Antibodi dalam
Plasma
Aman Ditransfusi
Recipient
Donor
A
A
B
A, AB
A, O
B
B
A
B, AB
B, O
AB
A + B
-
AB
A, B, AB, O
O
-
A + B
A, B, AB, O
O

Pada tahun 1900 Dr. Loustiner menemukan 4 macam golongan darah :
  1.  Golongan darah A
  2.  Golongan darah B
  3.  Golongan darah AB
  4.  Golongan darah O
Selain itu tahun 1940 ditemukan golongan darah baru yaitu Rhesus Faktor positif dan rhesus faktor negatif pada sel darah merah (erythrocyte).

  • Apabila seseorang memiliki protein di permukaan sel darahnya, maka orang tersebut diidentifikasikan rhesus positif (+).
  • Apabila seseorang tidak memiliki protein di permukaan sel darahnya, maka orang tersebut diidentifikasikan rhesus negatif (-).
  • Rhesus Faktor positif banyak terdapat pada orang Asia dan Negatif Pada orang Eropa, America, Australia.
  • Bila rhesus darah beda dengan suami, dokter bisa memberikan tindakan pencegahan terbentuknya zat antirheus dengan obat anti-Rhogama globulin (RhoGAM)/ anti D atau Rh Immunuglobulin. RhoGAM disuntikkan pada usia kehamilan 28 minggu dan saat persalinan. 
  • Bila ibu mempunyai rheusus negatif, atau ketidakcocokan golongan darah antara janin dan ibu baru diketahui usia persalinan, suntikan RhoGAM untuk ibu sebaiknya diberikan dalam waktu maksimal 72 jam setelah persalinan. rhoGAM efektif hanya berlangsung 12 minggu, sehingga setelah lewat masa tersebut harus mendapat suntikan kembali agar kehamilan berikutnya tidak bermasalah.
Ayah Rh +
Ayah Rh -
Ibu Rh +
Janin Rh +
Tidak bermasalah
Janin Rh +
Tidak bermasalah.
Ibu Rh -
Janin Rh +
Akan timbul masalah
  karena beda dengan ibu.
Janin Rh –
Tidak bermasalah.




KOMPONEN DARAH

1.   Darah lengkap (whole blood) 

  • Untuk mengatasi perdarahan akut dan masif, meningkatkan dan mempertahankan proses pembekuan. 
  • Darah lengkap yang diberikan dengan golongan ABO dan Rh yang diketahui.
  • Bisanya tersedia dalam volume 400-500 ml dengan masa hidup 21 hari. 
  • Indikasi
  • a)  Penggantian volume pada pasien dengan syok hemorrhagic, trauma atau luka bakar
  • b) Klien dengan perdarahan masif dan telah kehilangan lebih dari 25 persen dari volume darah total
2. Packed Red Blood cells (RBCs)
  • Komponen ini mengandung sel darah merah, SDP, dan trombosit karena sebagian plasma telah dihilangkan (80 %).
  • Tersedia volume 250 ml. Diberikan selama 2 sampai 4 jam, dengan golongan darah ABO dan Rh yang diketahui.
  • Masa hidup komponen ini 21 hari.
  • Indikasi :
  • a) Pasien dengan kadar Hb rendah
  • b) Pasien anemia karena kehilangan darah saat pembedahan
  • c) Pasien dengan massa sel darah merah rendah

3. White Blood Cells (WBC atau leukocyte)
  • Komponen ini terdiri dari darah lengkap dengan isi seperti RBCs, plasma dihilangkan 80 %
  • Biasanya tersedia dalam volume 150 ml.
  • Indikasi :
  • a) Pasien sepsis yang tidak berespon dengan antibiotik (khususnya untuk pasien dengan kultur darah positif, demam persisten /38,3° C dan granulositopenia)
4. Leukocyte –poor RBCs
  • Komponen ini sama dengan RBCs, tapi leukosit dihilangkan sampai 95 %, digunakan bila kelebihan plasma dan antibody tidak dibutuhkan.
  • Komponen ini tersedia dalam volume 200 ml, waktu pemberian 1 ½ sampai 4 jam.
  • IndikasiPasien dengan penekanan system imun (imunokompromise)

5. Platelet/ Trombosit
  • Komponen ini biasanya digunakan untuk mengobati kelainan perdarahan atau jumlah trombosit yang rendah.
  • Volume bervariasi biasanya 35-50 ml/unit, untuk pemberian biasanya memerlukan beberapa kantong.
  • Periksa hitung trombosit pada 1 dan 24 jam setelah pemberian.
  • Indikasi 
  • a) Pasien dengan trombositopenia (karena penurunan trombosit, peningkatan pemecahan trombosit
  • b) Pasien dengan leukemia dan marrow aplasia