Fundamentals Of Nursing NCLEX Quiz 48

1. Nurse Paulo has received a blood unit from the blood bank and has rechecked the blood bag properly with nurse Edward. Prior the facilitation of the blood transfusion. nurse Paulo priority check which of the following?

Intake and output.

NPO standing order.

Vital signs.

Skin turgor.

The nurse must assess the vital signs before and 15 minutes after the procedure so that any changes during the transfusion may indicate a transfusion reaction is happening.

Explanation

The nurse must assess the vital signs before and 15 minutes after the procedure so that any changes during the transfusion may indicate a transfusion reaction is happening.

2. Which nursing intervention takes highest priority when caring for a newly admitted client who's receiving a blood transfusion?

Warming the blood prior transfusion.

Informing the client that the transfusion usually takes 4 to 6 hours.

Documenting blood administration in the client chart.

Instructing the client to report any itching. chest pain. or dyspnea.

This will help the nurse take immediate action incase a reaction happens during a transfusion.

Explanation

This will help the nurse take immediate action incase a reaction happens during a transfusion.

3. A client is receiving a first-time blood transfusion of packed RBC. How long should the nurse stay and monitor the client to ensure a transfusion reaction will not happen?

15 minutes.

30 minutes.

45 minutes.

60 minutes.

Usually. a transfusion reaction occurs within the 15 minutes of a transfusion.

Explanation

Usually. a transfusion reaction occurs within the 15 minutes of a transfusion.

4. A nurse is caring for a combative client who is ordered to have a nutritional therapy using parenteral nutrition (PN). The nurse should plan which of the following measures to prevent the client from injury?

Monitor blood glucose twice a day.

Instruct the relative to stay with the nurse.

Measure 24-hour intake and output.

Secure all connections in the parenteral system.

The nurse should plan to secure all connections in the tubing. This will prevent the client from pulling the connections apart.

Explanation

The nurse should plan to secure all connections in the tubing. This will prevent the client from pulling the connections apart.

5. A client is brought to the emergency department having experienced blood loss due to a deep puncture wound. A 3 unit Fresh-frozen plasma (FFP) is ordered. The nurse determines that the reason behind this order is to:

Provide clotting factors and volume expansion.

Increase hemoglobin. hematocrit. and neutrophil levels.

Treat platelet dysfunction.

Treat thrombocytopenia.

Fresh-frozen plasma may be used to provide clotting factors or volume expansion. It is rich in clotting factors and can be thawed quickly and transfused right away.Option B is incorrect since it will not specifically increase the hemoglobin. hematocrit. and neutrophil level.Options C and D are incorrect since FFP does not contain any platelet.

Explanation

Fresh-frozen plasma may be used to provide clotting factors or volume expansion. It is rich in clotting factors and can be thawed quickly and transfused right away.Option B is incorrect since it will not specifically increase the hemoglobin. hematocrit. and neutrophil level.Options C and D are incorrect since FFP does not contain any platelet.

6. A nurse observes the client receiving fat emulsions is having hives. A nurse reviews the client's history and note in which of the following may cause about by the complaint of the client?

Allergy to an egg.

Allergy to peanut.

Allergy to shellfish.

Allergy to corn.

Fat emulsions (lipids) contain egg yolk phospholipids and should not be given to clients with egg allergies.

Explanation

Fat emulsions (lipids) contain egg yolk phospholipids and should not be given to clients with egg allergies.

7. Nurse Spencer is caring for an anorexic client who is having total parenteral nutrition solution for the first time. Which of the following assessments requires the most immediate attention?

Dry sticky mouth.

Temperature of 100° Fahrenheit.

Blood glucose of 210 mg/dl.

Fasting blood sugar of 98 mg/dl.

Total parenteral nutrition formula contains dextrose range from 5% to 70%. A blood glucose level of 210mg/dl is considered high.

Explanation

Total parenteral nutrition formula contains dextrose range from 5% to 70%. A blood glucose level of 210mg/dl is considered high.

8. Nurse Russell is preparing to give a total parenteral nutrition using a central line. Place the following steps for administration in the correct order?(1. Connect the tubing to the central line.||2. Regulate the electric infusion pump at the ordered rate.||3. Maintain aseptic technique when handling the injection cap.||4. Check the solution for cloudiness. particles. or a change in color.||5. Prime the IV tubing through an infusion pump.||6. Select and flush the correct tubing and filter.)

4. 3. 5. 6. 1. and 2.

6. 4. 5. 1. 3. and 2.

4. 6. 5. 3. 1. and 2.

3. 4. 6. 1. 5. and 2.

The correct order for the steps of administering total parenteral nutrition using a central line is as follows:
1. Check the solution for cloudiness, particles, or a change in color.
2. Maintain aseptic technique when handling the injection cap.
3. Select and flush the correct tubing and filter.
4. Prime the IV tubing through an infusion pump.
5. Connect the tubing to the central line.
6. Regulate the electric infusion pump at the ordered rate.

Explanation

The correct order for the steps of administering total parenteral nutrition using a central line is as follows:
1. Check the solution for cloudiness, particles, or a change in color.
2. Maintain aseptic technique when handling the injection cap.
3. Select and flush the correct tubing and filter.
4. Prime the IV tubing through an infusion pump.
5. Connect the tubing to the central line.
6. Regulate the electric infusion pump at the ordered rate.

9. A client receiving parenteral nutrition (PN) complains of shortness of breath and shoulder pain. A nurse notes that the client has an increased pulse rate. The nurse determines that the client is experiencing which complication of PN therapy?

Air embolism.

Hypervolemia.

Hyperglycemia.

Pneumothorax.

Pneumothorax might happen during a parenteral therapy due to inexact catheter placement. In order to prevent this. the nurse obtains a chest x-ray after insertion of the catheter to ensure proper catheter placement.

Explanation

Pneumothorax might happen during a parenteral therapy due to inexact catheter placement. In order to prevent this. the nurse obtains a chest x-ray after insertion of the catheter to ensure proper catheter placement.

10. Nurse Amanda is caring for a client with severe blood loss who is prescribed with multiple transfusion of blood. Nurse Amanda obtains which most essential piece of equipment to prevent the risk of cardiac dysrhythmias?

Cardiac monitor.

Blood warmer.

ECG machine.

Infusion pump.

Rapid transfusion of cool blood put the client at risk for cardiac dysrhythmias.Options A and C are used to assess for any blood transfusion-related complication. but they do not prevent the occurrence of cardiac dysrhythmia.Option D is not beneficial in this case since the infusion must be given rapidly.

Explanation

Rapid transfusion of cool blood put the client at risk for cardiac dysrhythmias.Options A and C are used to assess for any blood transfusion-related complication. but they do not prevent the occurrence of cardiac dysrhythmia.Option D is not beneficial in this case since the infusion must be given rapidly.