Fundamentals Of Nursing NCLEX Quiz 49

1. Nurse Jay is caring for a client with an ongoing transfusion of packed RBCs when suddenly the client is having difficulty of breathing. Skin is flushed and having chills. Which action should nurse Jay take first?

Administer oxygen.

Place the client on droplight.

Check the client’s temperature.

Stop the transfusion.

The client in this situation is experiencing a transfusion reaction, so the priority action of the nurse is to first stop the transfusion.

Explanation

The client in this situation is experiencing a transfusion reaction, so the priority action of the nurse is to first stop the transfusion.

2. A client has an order to receive one unit of packed RBCs. The nurse makes sure which of the following intravenous solutions to hang with the blood product at the client’s bedside?

0.9% sodium chloride.

5% dextrose in 0.9% sodium chloride.

Balanced Multiple Maintenance Solution with 5% Dextrose.

5% dextrose in 0.45% sodium chloride.

0.9% sodium chloride is a standard solution used to follow infusion of blood products. Options B. C. and D: IV solution containing dextrose in water will hemolyze red cells.

Explanation

0.9% sodium chloride is a standard solution used to follow infusion of blood products. Options B. C. and D: IV solution containing dextrose in water will hemolyze red cells.

3. To verify the age of blood cells in the blood. The nurse will check which of the following?

Blood type.

Blood group.

Blood identification number.

Blood expiration date.

The safe storage of blood usually takes 35 days. Examining the expiration date is an important responsibility of a nurse prior to hanging the blood.

Explanation

The safe storage of blood usually takes 35 days. Examining the expiration date is an important responsibility of a nurse prior to hanging the blood.

4. Nurse Rick is administering 2 unit packed RBCs on a client with low hemoglobin. The nurse will prepare which of the following in order to transfuse the blood?

Microfusion set.

Polyvol Pro Burette Set.

Photofusion set.

Tubing with an in-line filter.

The in-line filter helps ensure that any particles larger than the size of the filter are caught in the filter and are not infused with the client. Option A is incorrect since the tubing that should be used is a macro drip. Option B is used for administration of IV medication infusion. Option C is incorrect since blood does not need any protection from light.

Explanation

The in-line filter helps ensure that any particles larger than the size of the filter are caught in the filter and are not infused with the client. Option A is incorrect since the tubing that should be used is a macro drip. Option B is used for administration of IV medication infusion. Option C is incorrect since blood does not need any protection from light.

5. After terminating the transfusion during a reaction. Which action should the nurse immediately be taken next?

Run a solution of 5% dextrose in water.

Run normal saline at a keep-vein-open rate.

Remove the IV line.

Fast drip 200ml normal saline.

The nurse will infuse normal saline at a KVO rate to keep the patency of the IV line while waiting for further orders from the physician. Option A: IV solution containing dextrose will hemolyze the red cells. Option C: The nurse will not remove the IV line because then there will be no IV access route. Option D: Doing a fast drip will potentially lead to congestion and is not done without the physician's order.

Explanation

The nurse will infuse normal saline at a KVO rate to keep the patency of the IV line while waiting for further orders from the physician. Option A: IV solution containing dextrose will hemolyze the red cells. Option C: The nurse will not remove the IV line because then there will be no IV access route. Option D: Doing a fast drip will potentially lead to congestion and is not done without the physician's order.

6. Packed red blood cells have been prescribed for a client with low hemoglobin and hematocrit levels. The nurse takes the client's temperature before hanging the blood transfusion and records 100.8 °F. Which action should the nurse take?

Give an antipyretic and begin the transfusion.

Proceed with the transfusion.

Administer an antihistamine and begin the transfusion.

Delay hanging the blood and inform the physician.

If the client has a temperature higher than 100 ° F. The unit of blood should be hung and delayed until the physician is notified and has the opportunity to give further order. Options A and C are incorrect since the administration of the medicine will need the physician’s prescription. Option B: The decision to administer the blood is not within the scope of nurse practice.

Explanation

If the client has a temperature higher than 100 ° F. The unit of blood should be hung and delayed until the physician is notified and has the opportunity to give further order. Options A and C are incorrect since the administration of the medicine will need the physician’s prescription. Option B: The decision to administer the blood is not within the scope of nurse practice.

7. A client is receiving a platelet transfusion. The nurse determines that the client is gaining from this therapy if the client exhibits which of the following.

Less frequent febrile episodes.

Increased level of hematocrit.

Fewer episodes of bleeding.

Increased level of hemoglobin.

Platelet transfusions may be given to prevent bleeding when the platelet count falls down. Option A: A decline in the febrile episode will happen after the transfusion of agranulocytes. Options B and D: An increased level of hemoglobin and hematocrit will happen after the transfusion of red blood cells.

Explanation

Platelet transfusions may be given to prevent bleeding when the platelet count falls down. Option A: A decline in the febrile episode will happen after the transfusion of agranulocytes. Options B and D: An increased level of hemoglobin and hematocrit will happen after the transfusion of red blood cells.

8. A client is receiving a transfusion of one unit of cryoprecipitate. The nurse will review which of the following laboratory studies to assess the effectiveness of the therapy?

Serum electrolytes.

White blood cell count.

Coagulation studies.

Hematocrit count.

The evaluation of effective response of a cryoprecipitate transfusion is assessed by monitoring coagulation studies and fibrinogen levels.

Explanation

The evaluation of effective response of a cryoprecipitate transfusion is assessed by monitoring coagulation studies and fibrinogen levels.

9. A nurse is caring for a client requiring surgery and is ordered to have standby blood secured in case a blood transfusion is needed during or after the procedure. The nurse suggested to the client to do which of the following to lessen the risk of possible transfusion reaction?

Request that any donated blood be screened twice by the blood bank.

Take iron supplements prior to the surgery and eat green leafy vegetables.

Make an autologous blood donation.

Have a family member donate their own blood.

A donation of the own blood is autologous. Doing this will prevent the risk of transfusion reaction.

Explanation

A donation of the own blood is autologous. Doing this will prevent the risk of transfusion reaction.

10. Nurse Daniel is caring for a client receiving a transfusion of packed red blood cells (PRBCs). The client started to vomit and to be nauseous. The client’s blood pressure is 95/40 mm Hg from a baseline of 110/70 mm Hg. The client’s temperature is 100.5°F orally from a baseline of 99.5°F orally. The nurse understands that the client may be experiencing which of the following.

Circulatory overload.

Delayed transfusion reaction.

Hypocalcemia.

Septicemia.

Septicemia happens with the transfusion of blood that is contaminated with microorganisms. Assessment includes the rapid onset of high fever and chills, hypotension, nausea, diarrhea, vomiting, and shock. Option A: Circulatory overload causes hypertension, cough, dyspnea, chest pain, tachycardia, and wheezing upon auscultation. Option B: Delayed reaction can occur days to years after a transfusion. It causes fever, rashes, mild jaundice. and oliguria or anuria. Option C: Hypocalcemia causes paresthesias, tetany, muscle cramps, hyperactive reflexes. Positive Trousseau's sign and positive Chovstek's sign.

Explanation

Septicemia happens with the transfusion of blood that is contaminated with microorganisms. Assessment includes the rapid onset of high fever and chills, hypotension, nausea, diarrhea, vomiting, and shock. Option A: Circulatory overload causes hypertension, cough, dyspnea, chest pain, tachycardia, and wheezing upon auscultation. Option B: Delayed reaction can occur days to years after a transfusion. It causes fever, rashes, mild jaundice. and oliguria or anuria. Option C: Hypocalcemia causes paresthesias, tetany, muscle cramps, hyperactive reflexes. Positive Trousseau's sign and positive Chovstek's sign.