Reduction of Risk Potential: Practice Questions & Explanations

This is anaphylactic reaction to the IV antibiotic. Anaphylaxis is a life-threatening systemic allergic reaction requiring immediate action: (1) Stop the offending agent immediately — close the IV clamp; (2) Maintain the airway — anaphylaxis can cause rapid laryngeal swelling; (3) Call for help (rapid response or code team); (4) Administer epinephrine IM (0.3-0.5 mg adult dose, 1:1000 solution, IM in vastus lateralis) — epinephrine is first-line and given immediately; (5) Position supine with legs elevated unless respiratory distress requires head elevated; (6) Apply high-flow oxygen; (7) Establish second IV; bolus fluids for hypotension; (8) Continuous monitoring; (9) Prepare for intubation. Secondary medications: diphenhydramine (antihistamine), methylprednisolone (corticosteroid), bronchodilator if wheezing. After stabilization: identify the allergen, document the reaction, update the medical record allergy list, place an allergy band, educate the client and family. Biphasic reactions can occur 8-12 hours later, so observation period is required.

Thoracentesis is the insertion of a needle through the chest wall to remove fluid from the pleural space. Main complications: (1) Pneumothorax — air enters the pleural space, possibly causing lung collapse; signs include sudden shortness of breath, sharp chest pain, decreased or absent breath sounds on affected side, tracheal deviation (large pneumothorax), hypoxia; (2) Bleeding; (3) Re-expansion pulmonary edema (if too much fluid removed too quickly); (4) Infection. Post-procedure nursing: (1) Position the client upright or on the unaffected side initially; (2) Monitor respiratory status frequently (vital signs every 15 minutes for 1 hour, then every hour, then per protocol); (3) Auscultate breath sounds bilaterally and compare to pre-procedure; (4) Monitor for shortness of breath, chest pain, hemoptysis, hypoxia; (5) Chest x-ray usually ordered to verify lung expansion and rule out pneumothorax; (6) Document fluid removed (color, character, amount). Report sudden change in respiratory status immediately. The same vigilance applies after any chest procedure: central line insertion, lung biopsy, chest tube placement.

ACUTE HAEMOLYTIC TRANSFUSION REACTION (AHTR) is the most life-threatening transfusion complication and is caused by ABO blood group incompatibility. CLASSIC SIGNS (appear within the first 15-50 mL): Sudden chills and fever; Low back pain (retroperitoneal lysis of red blood cells); Dark/red-brown urine (haemoglobinuria from lysed red blood cell haemoglobin); Chest tightness and dyspnoea; Hypotension and tachycardia; Flank pain; Anxiety and feeling of 'impending doom.' NURSING RESPONSE — SEQUENCE: (1) STOP THE TRANSFUSION IMMEDIATELY — the most critical step; do not flush the line; (2) MAINTAIN IV ACCESS — keep the IV line open with normal saline using a NEW IV tubing set (the blood-containing tubing must not be used to infuse anything further); (3) NOTIFY THE PROVIDER AND BLOOD BANK IMMEDIATELY; (4) MONITOR vital signs every 5 minutes; (5) SEND the blood bag, new tubing, and blood samples to the blood bank for investigation; (6) COLLECT urine sample (haemoglobinuria confirms AHTR); (7) SUPPORT as ordered: IV fluids; vasopressors if hypotensive; maintain urine output above 100 mL/hour to prevent acute tubular necrosis from haemoglobin precipitating in renal tubules; PREVENTION: Two-nurse verification of patient ID and blood product compatibility before every transfusion is the primary prevention measure.

PRE-PROCEDURE ASSESSMENT for colonoscopy must identify bleeding risk factors because colonoscopy can involve biopsy, polyp removal, and other interventions that create mucosal wounds. ANTICOAGULANTS: Warfarin, direct oral anticoagulants (apixaban, rivaroxaban, dabigatran), and antiplatelet agents (clopidogrel, aspirin) all increase bleeding risk during endoscopic procedures; THE PROVIDER DECISION: For elective colonoscopy with polypectomy anticipated: warfarin is typically held 5 days before with or without heparin bridging (depending on thromboembolic risk); direct oral anticoagulants held 24-48 hours before; antiplatelet decisions are case-specific; for diagnostic-only colonoscopy with low bleeding risk, some anticoagulants may be continued at reduced risk; INR SHOULD BE CHECKED: For patients on warfarin, INR should be therapeutic or sub-therapeutic before the procedure; an INR above 2.0-2.5 is typically a contraindication to proceeding; NURSING ROLE: Accurate medication reconciliation — specifically ask about blood thinners, herbals (fish oil, vitamin E, ginkgo also affect bleeding); report anticoagulant use to the provider/gastroenterologist; ensure the patient understands any medication-holding instructions; ALSO IMPORTANT: NPO status, bowel prep completion, allergies to sedating agents, and implanted devices (pacemakers — electrocautery precautions).

POST-SPINAL SURGERY NEUROLOGICAL DETERIORATION is a surgical emergency. NEW ONSET OF MOTOR DEFICIT (inability to move toes) in a post-laminectomy or spinal fusion patient is NEVER normal — it requires IMMEDIATE assessment and intervention. POSSIBLE CAUSES: EPIDURAL HAEMATOMA — blood collects in the epidural space and compresses the spinal cord; most common cause of post-spinal surgery neurological deficit; WINDOW FOR INTERVENTION: neurological function can often be preserved if decompressive surgery occurs within 4-6 hours of onset; beyond this window, deficits may become permanent; HARDWARE COMPLICATION — screw or cage malpositioning; OEDEMA — surgical site oedema compressing neural structures. WHAT NOT TO DO: Do NOT administer analgesics and re-assess — the pain and neurological deficit require immediate evaluation, and analgesics may mask the assessment; Do NOT assume it's normal post-operative discomfort — motor deficit is NEVER within normal range post-operatively; Do NOT wait — the speed of surgical decompression determines whether function can be preserved. NURSING ASSESSMENT TO REPORT: Exact onset time; baseline neurological assessment before surgery (what was normal for this patient?); current motor, sensory, and bowel/bladder function; vital signs; pain characteristics; AFTER NOTIFICATION: Prepare for emergency imaging (MRI or CT myelogram); possible emergency return to OR.