Adult Health Final Exam Nclex Review for
weeks 4-7-EXAM STUDY GUIDE ACCURATE
QUESTIONS AND CORRECT DETAILED
ANSWERS WITH RATIONALES || 100%
GUARANTEED PASS <BRAND NEW
VERSION>
a
the nurse has obtained a unit of blood from the blood bank and has checked the blood bag
properly with another nurse. Just before the beginning transfusion, the nurse assesses which of
the following items?
A. Vital signs B. Skin Color C. Urine output D. Latest hematocrit level.
c
The physician orders 2 units of packed RBCs to be administered to the client. At 0600 the night
shift nurse initiates the first unit's transfusion before going off shift. At 1000 the day shift nurse
notes the IV line has clotted off and the transfusion has not been completed. The nursing
assessment revealed the transfusion was only approximately 75% complete. Which of the
actions by the nurse is most appropriate?
A. Advise the blood bank about the delay for the next unit.
B. Restart another peripheral line with 0.9% NS and restart the blood transfusion with the
remaining blood unit.
C. Discontinue the transfusion.
D. Document the amount infused thus far and continue the transfusion."
4
About ten minutes after the nurse begins an infusion of packed RBCs, the patient complains of
chills, chest and back pain, and nausea. His face is flushed, and he's anxious. Which is the
priority nursing action?
,1. Administering antihistamines STAT for an allergic reaction.
2. Notifying the physician of a possible transfusion reaction.
3. Obtaining a urine and serum specimen to send to the lab immediately.
4. Stopping hte transfusion and maintaining a patent IV catheter."
4 (The most likely time for a blood transfusion reaction to occur is during the first 15 minutes
or first 50 mL of the infusion. If a blood transfusion reaction does occur, it is imperative to
keep an established I.V. line so that medication can be administered to prevent or treat
cardiovascular collapse in case of anaphylaxis. PRBCs should be administered through a 19-
gauge or larger needle; a peripherally inserted central catheter line is not recommended, in
order to avoid a slow flow. RBCs will hemolyze in dextrose or lactated Ringer's solution and
should be infused with only normal saline solution.)
The nurse is administering packed red blood cells (PRBCs) to a client. The nurse should first:
"1. Discontinue the I.V. catheter if a blood transfusion reaction occurs.
2. Administer the PRBCs through a percutaneously inserted centralcatheter line with a 20-gauge
needle.
3. Flush PRBCs with 5% dextroseand 0.45% normal saline solution.
4. Stay with the client during thefirst 15 minutes of infusion.
3
The nurse enters a client's room to assess the client, who began receiving a blood transfusion 45
minutes earlier, and notes that the client is flushed and dyspneic. On assessment, the nurse
auscultates the presence of crackles in the lung bases. The nurse determines that this client
most likely is experiencing which complication of blood transfusion therapy?
1) Bacteriemia.
2) Hypovolemia.
3) Fluid overload
4) Transfusion reaction
b (Patients who are likely to have a transfusion reaction will more often exhibit signs within
the first 15 minutes that the blood is infusing)
"Before starting a transfusion of packed red blood cells for an anemic patient, the nurse would
arrange for a peer to monitor his or her other assigned patients for how many minutes when
the nurse begins the transfusion?
A. 5 minutes
B. 15 minutes
,C. 60 minutes
D. 30 minutes"
3
A 52-year-old woman is admitted with a new diagnosis of gastrointestinal (GI) bleed. The
physician has ordered the client to receive 2 units of packed red blood cells (PRBCs) for a
hemoglobin (Hgb) of 6.8g/dL. The nurse begins the infusion of the first unit at 100mL/hr.
Firfteen minutes after the start of the infusion, the client complains that she is feeling chilled, is
short of breath, and is experiencing lumbar pain rated 8 on a 1-10 scale. Whic of the following
should be the nurse's FIRST action.
"1. Obtain vital signs and notify the physician of potential reaction
2. Slow the infusion to 75mL/hr and reassess in 15 minutes
3. Stop the infusion and run normal saline (NS) to keep the vein open (KVO)
4. Administer PRN pain medication as ordered, apply oxygen at 2 L/min, and provide an
additional blanket"
3 (The client cannot donate blood for 6months after a pregnancy because of thenutritional
demands on the mother.)
The nurse is working in a blood bank facility procuring units of blood from donors. Which client
would not be a candidate to donate blood?
1.The client who had wisdom teeth removed a week ago.
2.The nursing student who received a measles immunization 2 months ago.
3. The mother with a six (6)-week-old newborn.
4.The client who developed an allergy to aspirin in childhood
2 (Blood is a medium for bacterial growth, and any bacteria contaminating the unit will begin
to grow if left outside of a controlled)
Which statement is the scientific rationale for infusing a unit of blood in less than four (4)
hours?
"1. The blood will coagulate if left out of the refrigerator for >four (4) hours.
2. The blood has the potential for bacterial growth if allowed to infuse longer.
3. The blood components begin to break down after four (4) hours.
4. The blood will not be affected; this is a laboratory procedure."
a
, The nurse who is about to give a blood transfusion knows that blood cells start to deteriorate
after a certain period of time. Which of the following itens is important to check regarding the
age of blood cells before the transfusion is begun?
A. Expiration date
B. Presence of clots
C. Blood group and type
D. Blood identification number"
4 (The unlicensed nursing assistant can assist a client to brush the teeth. Instructions about
using soft-bristle toothbrushes and the need to report to the nurse any pink or bleeding
should be given prior to delegating the procedure. (CORRECT)
The nurse and unlicensed nursing assistant are caring for clients on an oncology floor.Which
nursing task would be delegated to the unlicensed nursing assistant?"
1. Assess the urine output on a client who has had a blood transfusion reaction.
2. Take the first 15 minutes of vital signs on a client receiving a unit of PRBCs.
3. Auscultate the lung sounds of a client prior to a transfusion.
4. Assist a client who received ten (10) units of platelets in brushing teeth.
a (Red blood cells contain antigens and antibodies that must be matched between donor and
recipient. The blood products in options 2-4 do not contain red cells. Thus, they require no
cross-match.)
"Cris asks the nurse whether all donor blood products are cross-matched with the recipient to
prevent a transfusion reaction. Which of the following always require cross-matching?
a. packed red blood cells
b. platelets
c. plasma
d. granulocytes"
d (Infectious viruses, such as human immunodeficiency virus (HIV), human herpesvirus,
hepatitis B and C type 6 (HSV-6), Epstein-Barr virus (EBV), human T-cell leukemia virus type 1
(HTLV-1), and cytomegalovirus (CMV), and other agents, such as the agent that causes
malaria, can be transmitted by blood transfusion. Leukocyte-reduced blood products
drastically reduce the risk of blood transfusion-associated viral infections, including CMV.
"Complications of transfusions that can be decreased by the use of leukocyte depletion or
reduction of RBC transfusion area.
weeks 4-7-EXAM STUDY GUIDE ACCURATE
QUESTIONS AND CORRECT DETAILED
ANSWERS WITH RATIONALES || 100%
GUARANTEED PASS <BRAND NEW
VERSION>
a
the nurse has obtained a unit of blood from the blood bank and has checked the blood bag
properly with another nurse. Just before the beginning transfusion, the nurse assesses which of
the following items?
A. Vital signs B. Skin Color C. Urine output D. Latest hematocrit level.
c
The physician orders 2 units of packed RBCs to be administered to the client. At 0600 the night
shift nurse initiates the first unit's transfusion before going off shift. At 1000 the day shift nurse
notes the IV line has clotted off and the transfusion has not been completed. The nursing
assessment revealed the transfusion was only approximately 75% complete. Which of the
actions by the nurse is most appropriate?
A. Advise the blood bank about the delay for the next unit.
B. Restart another peripheral line with 0.9% NS and restart the blood transfusion with the
remaining blood unit.
C. Discontinue the transfusion.
D. Document the amount infused thus far and continue the transfusion."
4
About ten minutes after the nurse begins an infusion of packed RBCs, the patient complains of
chills, chest and back pain, and nausea. His face is flushed, and he's anxious. Which is the
priority nursing action?
,1. Administering antihistamines STAT for an allergic reaction.
2. Notifying the physician of a possible transfusion reaction.
3. Obtaining a urine and serum specimen to send to the lab immediately.
4. Stopping hte transfusion and maintaining a patent IV catheter."
4 (The most likely time for a blood transfusion reaction to occur is during the first 15 minutes
or first 50 mL of the infusion. If a blood transfusion reaction does occur, it is imperative to
keep an established I.V. line so that medication can be administered to prevent or treat
cardiovascular collapse in case of anaphylaxis. PRBCs should be administered through a 19-
gauge or larger needle; a peripherally inserted central catheter line is not recommended, in
order to avoid a slow flow. RBCs will hemolyze in dextrose or lactated Ringer's solution and
should be infused with only normal saline solution.)
The nurse is administering packed red blood cells (PRBCs) to a client. The nurse should first:
"1. Discontinue the I.V. catheter if a blood transfusion reaction occurs.
2. Administer the PRBCs through a percutaneously inserted centralcatheter line with a 20-gauge
needle.
3. Flush PRBCs with 5% dextroseand 0.45% normal saline solution.
4. Stay with the client during thefirst 15 minutes of infusion.
3
The nurse enters a client's room to assess the client, who began receiving a blood transfusion 45
minutes earlier, and notes that the client is flushed and dyspneic. On assessment, the nurse
auscultates the presence of crackles in the lung bases. The nurse determines that this client
most likely is experiencing which complication of blood transfusion therapy?
1) Bacteriemia.
2) Hypovolemia.
3) Fluid overload
4) Transfusion reaction
b (Patients who are likely to have a transfusion reaction will more often exhibit signs within
the first 15 minutes that the blood is infusing)
"Before starting a transfusion of packed red blood cells for an anemic patient, the nurse would
arrange for a peer to monitor his or her other assigned patients for how many minutes when
the nurse begins the transfusion?
A. 5 minutes
B. 15 minutes
,C. 60 minutes
D. 30 minutes"
3
A 52-year-old woman is admitted with a new diagnosis of gastrointestinal (GI) bleed. The
physician has ordered the client to receive 2 units of packed red blood cells (PRBCs) for a
hemoglobin (Hgb) of 6.8g/dL. The nurse begins the infusion of the first unit at 100mL/hr.
Firfteen minutes after the start of the infusion, the client complains that she is feeling chilled, is
short of breath, and is experiencing lumbar pain rated 8 on a 1-10 scale. Whic of the following
should be the nurse's FIRST action.
"1. Obtain vital signs and notify the physician of potential reaction
2. Slow the infusion to 75mL/hr and reassess in 15 minutes
3. Stop the infusion and run normal saline (NS) to keep the vein open (KVO)
4. Administer PRN pain medication as ordered, apply oxygen at 2 L/min, and provide an
additional blanket"
3 (The client cannot donate blood for 6months after a pregnancy because of thenutritional
demands on the mother.)
The nurse is working in a blood bank facility procuring units of blood from donors. Which client
would not be a candidate to donate blood?
1.The client who had wisdom teeth removed a week ago.
2.The nursing student who received a measles immunization 2 months ago.
3. The mother with a six (6)-week-old newborn.
4.The client who developed an allergy to aspirin in childhood
2 (Blood is a medium for bacterial growth, and any bacteria contaminating the unit will begin
to grow if left outside of a controlled)
Which statement is the scientific rationale for infusing a unit of blood in less than four (4)
hours?
"1. The blood will coagulate if left out of the refrigerator for >four (4) hours.
2. The blood has the potential for bacterial growth if allowed to infuse longer.
3. The blood components begin to break down after four (4) hours.
4. The blood will not be affected; this is a laboratory procedure."
a
, The nurse who is about to give a blood transfusion knows that blood cells start to deteriorate
after a certain period of time. Which of the following itens is important to check regarding the
age of blood cells before the transfusion is begun?
A. Expiration date
B. Presence of clots
C. Blood group and type
D. Blood identification number"
4 (The unlicensed nursing assistant can assist a client to brush the teeth. Instructions about
using soft-bristle toothbrushes and the need to report to the nurse any pink or bleeding
should be given prior to delegating the procedure. (CORRECT)
The nurse and unlicensed nursing assistant are caring for clients on an oncology floor.Which
nursing task would be delegated to the unlicensed nursing assistant?"
1. Assess the urine output on a client who has had a blood transfusion reaction.
2. Take the first 15 minutes of vital signs on a client receiving a unit of PRBCs.
3. Auscultate the lung sounds of a client prior to a transfusion.
4. Assist a client who received ten (10) units of platelets in brushing teeth.
a (Red blood cells contain antigens and antibodies that must be matched between donor and
recipient. The blood products in options 2-4 do not contain red cells. Thus, they require no
cross-match.)
"Cris asks the nurse whether all donor blood products are cross-matched with the recipient to
prevent a transfusion reaction. Which of the following always require cross-matching?
a. packed red blood cells
b. platelets
c. plasma
d. granulocytes"
d (Infectious viruses, such as human immunodeficiency virus (HIV), human herpesvirus,
hepatitis B and C type 6 (HSV-6), Epstein-Barr virus (EBV), human T-cell leukemia virus type 1
(HTLV-1), and cytomegalovirus (CMV), and other agents, such as the agent that causes
malaria, can be transmitted by blood transfusion. Leukocyte-reduced blood products
drastically reduce the risk of blood transfusion-associated viral infections, including CMV.
"Complications of transfusions that can be decreased by the use of leukocyte depletion or
reduction of RBC transfusion area.
