Saunders Comprehensive Review for
the NCLEX: Ch 69 Complex Care
Exam Questions & Answers (Grade
A+)
856. A client had a 100 mL bag of 5% dextrose in 0.9% sodium
chloride hung at 1500. The nurse making rounds at 1545 finds that
the client is complaining of a pounding headache and is dyspneic,
experiencing chills, and apprehensive, with an increased pulse rate.
The intravenous bag (IV) has 400 mL remaining. The nurse should
take which action FIRST?
1. Slow the IV infusion
2. Sit the client up in bed
3. Remove the IV catheter
4. Call the primary health care provider (PHCP) -
correct answer ✅Answer: 1
Rationale: the client's symptoms are compatible with circulatory
overload. This may be verified by noting that 600mL has been
infused in the course of 45 minutes. The first action of the nurse is
to slow the infusion. Other actions may be followed in rapid
sequence. The nurse may elevate the head of the bed to aid in the
client's breathing if necessary. The nurse also notifies the PCHP. the
IV catheter is not removed; it may be needed for the administration
of medications to resolve the complication.
,Saunders Comprehensive Review for
the NCLEX: Ch 69 Complex Care
Exam Questions & Answers (Grade
A+)
857. Packed red blood cells have been prescribed for a female client
with anemia who has a hemoglobin level of 7.6 g/dL (76 mol/L) and
a hematocrit level of 30% (0.30). The nurse takes the client's
temperature before the blood transfusion and records 100.6
degrees Fahrenheit (38.1 degrees Celsius) orally. Which action
should the nurse take?
1. Begin the transfusion as prescribed
2. Administer an antihistamine and begin the transfusion
3. Administer 2 tablets of acetaminophen
4. Delay hanging the blood and notify the primary health care
provider (PHCP) -
correct answer ✅Answer: 4
Rationale: If the client has a temperature higher than 100 degrees
F, the unit of blood should not be hung until the PHCP is notified
and has the opportunity to give further instructions. The PHCP will
likely prescribe that the blood be administered regardless of the
temperature or may instruct the nurse to administer prescribed
acetaminophen and wait until the temperature has decreased
before administration, but the decision is not within the nurse's
, Saunders Comprehensive Review for
the NCLEX: Ch 69 Complex Care
Exam Questions & Answers (Grade
A+)
scope of practice to make. The nurse needs a PHCPs prescription to
administer medication to the client.
858. The nurse is caring for a client experiencing acute lower
gastrointestinal bleeding. In developing the plan of care, which
priority problem should the nurse assign to this client?
1. deficient fluid volume related to acute blood loss
2. risk for aspiration related to acute bleeding in the GI tract
3. risk for infection related to acute disease process and
medications
4. Imbalanced nutrition, less than body requirements, related to
lack of nutrients and increased metabolism -
correct answer ✅Answer 1
Rationale: the priority problem for the client with a cute
gastrointestinal bleeding among these options is deficient fluid
volume related to acute blood loss. This state can result in
decreased cardiac output and hypovolemic shock. Although
nutrition is a problem, fluid volume deficit is more of a priority. The
the NCLEX: Ch 69 Complex Care
Exam Questions & Answers (Grade
A+)
856. A client had a 100 mL bag of 5% dextrose in 0.9% sodium
chloride hung at 1500. The nurse making rounds at 1545 finds that
the client is complaining of a pounding headache and is dyspneic,
experiencing chills, and apprehensive, with an increased pulse rate.
The intravenous bag (IV) has 400 mL remaining. The nurse should
take which action FIRST?
1. Slow the IV infusion
2. Sit the client up in bed
3. Remove the IV catheter
4. Call the primary health care provider (PHCP) -
correct answer ✅Answer: 1
Rationale: the client's symptoms are compatible with circulatory
overload. This may be verified by noting that 600mL has been
infused in the course of 45 minutes. The first action of the nurse is
to slow the infusion. Other actions may be followed in rapid
sequence. The nurse may elevate the head of the bed to aid in the
client's breathing if necessary. The nurse also notifies the PCHP. the
IV catheter is not removed; it may be needed for the administration
of medications to resolve the complication.
,Saunders Comprehensive Review for
the NCLEX: Ch 69 Complex Care
Exam Questions & Answers (Grade
A+)
857. Packed red blood cells have been prescribed for a female client
with anemia who has a hemoglobin level of 7.6 g/dL (76 mol/L) and
a hematocrit level of 30% (0.30). The nurse takes the client's
temperature before the blood transfusion and records 100.6
degrees Fahrenheit (38.1 degrees Celsius) orally. Which action
should the nurse take?
1. Begin the transfusion as prescribed
2. Administer an antihistamine and begin the transfusion
3. Administer 2 tablets of acetaminophen
4. Delay hanging the blood and notify the primary health care
provider (PHCP) -
correct answer ✅Answer: 4
Rationale: If the client has a temperature higher than 100 degrees
F, the unit of blood should not be hung until the PHCP is notified
and has the opportunity to give further instructions. The PHCP will
likely prescribe that the blood be administered regardless of the
temperature or may instruct the nurse to administer prescribed
acetaminophen and wait until the temperature has decreased
before administration, but the decision is not within the nurse's
, Saunders Comprehensive Review for
the NCLEX: Ch 69 Complex Care
Exam Questions & Answers (Grade
A+)
scope of practice to make. The nurse needs a PHCPs prescription to
administer medication to the client.
858. The nurse is caring for a client experiencing acute lower
gastrointestinal bleeding. In developing the plan of care, which
priority problem should the nurse assign to this client?
1. deficient fluid volume related to acute blood loss
2. risk for aspiration related to acute bleeding in the GI tract
3. risk for infection related to acute disease process and
medications
4. Imbalanced nutrition, less than body requirements, related to
lack of nutrients and increased metabolism -
correct answer ✅Answer 1
Rationale: the priority problem for the client with a cute
gastrointestinal bleeding among these options is deficient fluid
volume related to acute blood loss. This state can result in
decreased cardiac output and hypovolemic shock. Although
nutrition is a problem, fluid volume deficit is more of a priority. The
