Pre-Sim Quiz
1. The nurse has an order to administer normal saline 20 mL/kg bolus intravenously
over 30 minutes. The patient weighs 35 lb. How many milliliters should the nurse
prepare to administer? Round the weight in kilograms to the nearest whole number.
320
2. The nurse is assessing a patient with acute splenic sequestration crisis. Which
finding(s) would indicate that the patient is developing hypovolemic shock? (Select
all that apply.) Delayed capillary refill time, Pale extremities with weak peripheral
pulses, Decreased urine output with dark amber urine, Tachycardia and irritability
3. The nurse is assessing a 5-year-old patient with sickle cell anemia diagnosed with
acute splenic sequestration. The patient is sitting in bed playing video games with
her sister. Her vital signs are stable, with a blood pressure of 110/66 mmHg, heart
rate of 98 beats per minute (bpm), respiratory rate of 20 breaths per minute,
temperature of 99.5°F (37.5°C) oral, and pain rating of 2 out of 10 on the FACES
scale. On reassessment, which finding(s) would indicate that the patient's condition
is deteriorating? (Select all that apply.) FACES pain rating of 8 out of 10, Lethargy
and pallor, Blood pressure of 78/48 mmHg
4. A patient with sickle cell disease admitted with acute splenic sequestration has
ketorolac and morphine ordered intravenously for pain management. Which
principle(s) should the nurse be aware of when administering ketorolac? (Select all
that apply.) With prolonged use, ketorolac can increase bleeding time and the risk
for thrombotic events., Ketorolac may mask the signs and symptoms of an infection.
5. The nurse is assessing a patient with sickle cell anemia admitted several days ago
with vaso-occlusive pain crisis. Which finding(s) would indicate that the patient is
experiencing splenic sequestration crisis? (Select all that apply.) Splenomegaly,
Tachycardia, Greatly decreased hemoglobin
6. The nurse is developing a care plan for a patient with sickle cell anemia admitted
with vaso-occlusive crisis and acute splenic sequestration. The nurse knows that
which factor(s) can exacerbate the patient's condition and contribute to further
sickling? (Select all that apply.) Elevated temperature of 102.2°F (39.0°C),
Abdominal pain and tenderness, Distress over the family leaving the patient's
bedside, Lack of intake of oral fluids due to patient refusal
7. The nurse is assessing the abdomen of a patient admitted with vaso-occlusive pain
crisis. Place the steps of an abdominal assessment in order.
1)Have the patient lie down in a supine position.2)Inspect abdomen for size and
shape.3)Auscultate for bowel sounds in all four quadrants.4)Percuss the abdomen
working down from the costal margins.5)Lightly palpate the abdomen for
tenderness, muscle tone, and turgor.6)Palpate deeply from the lower quadrants
upward to the costal margins.
, 8. The nurse is preparing to administer a blood transfusion to a 5-year-old patient
with acute splenic sequestration. Which step(s) should be included during the
preparation and administration process? (Select all that apply.) Use a two-person
verification process to verify the patient and blood component., Follow institution
protocol for blood transfusion administration and management.
9. The nurse is reviewing laboratory results for a patient with sickle cell anemia
presenting with splenic sequestration. Which laboratory result(s) would the nurse
expect to be elevated? (Select all that apply.) Reticulocyte count, Erythrocyte
sedimentation rate, Bilirubin
10. A patient with sickle cell anemia who was admitted in vaso-occlusive crisis for leg
pain reports stomach pain and is guarding her left side. Which assessment(s) should
the nurse perform on this patient? (Select all that apply.) Observation of level of
consciousness, Inspection of skin color and temperature, Auscultation of heart and
lungs, Measurement of vital signs
SBAR Report
S
- Brittany Long is a 5-year-old patient receiving a blood transfusion, IVfluids, and
pain medication for management of acute splenic sequestration
B
- The parent states the patient had been complaining of right lower leg pain over the
last 2 days
- Brittany Long has a history of sickle cell disease, diagnosed at 6 months old
A
- Brittany was rating her pain at a 6/10 using the FACES scale. Spleen was palpated
and noticed to be enlarged
- Spleen was palpated and noticed to be enlarged
R
- Update the provider with the clinical status following the transfusion and for any
additional follow-up that is required
- Monitor administration of PRBCs and monitor patient for any signs of transfusion
reaction
1. The nurse has an order to administer normal saline 20 mL/kg bolus intravenously
over 30 minutes. The patient weighs 35 lb. How many milliliters should the nurse
prepare to administer? Round the weight in kilograms to the nearest whole number.
320
2. The nurse is assessing a patient with acute splenic sequestration crisis. Which
finding(s) would indicate that the patient is developing hypovolemic shock? (Select
all that apply.) Delayed capillary refill time, Pale extremities with weak peripheral
pulses, Decreased urine output with dark amber urine, Tachycardia and irritability
3. The nurse is assessing a 5-year-old patient with sickle cell anemia diagnosed with
acute splenic sequestration. The patient is sitting in bed playing video games with
her sister. Her vital signs are stable, with a blood pressure of 110/66 mmHg, heart
rate of 98 beats per minute (bpm), respiratory rate of 20 breaths per minute,
temperature of 99.5°F (37.5°C) oral, and pain rating of 2 out of 10 on the FACES
scale. On reassessment, which finding(s) would indicate that the patient's condition
is deteriorating? (Select all that apply.) FACES pain rating of 8 out of 10, Lethargy
and pallor, Blood pressure of 78/48 mmHg
4. A patient with sickle cell disease admitted with acute splenic sequestration has
ketorolac and morphine ordered intravenously for pain management. Which
principle(s) should the nurse be aware of when administering ketorolac? (Select all
that apply.) With prolonged use, ketorolac can increase bleeding time and the risk
for thrombotic events., Ketorolac may mask the signs and symptoms of an infection.
5. The nurse is assessing a patient with sickle cell anemia admitted several days ago
with vaso-occlusive pain crisis. Which finding(s) would indicate that the patient is
experiencing splenic sequestration crisis? (Select all that apply.) Splenomegaly,
Tachycardia, Greatly decreased hemoglobin
6. The nurse is developing a care plan for a patient with sickle cell anemia admitted
with vaso-occlusive crisis and acute splenic sequestration. The nurse knows that
which factor(s) can exacerbate the patient's condition and contribute to further
sickling? (Select all that apply.) Elevated temperature of 102.2°F (39.0°C),
Abdominal pain and tenderness, Distress over the family leaving the patient's
bedside, Lack of intake of oral fluids due to patient refusal
7. The nurse is assessing the abdomen of a patient admitted with vaso-occlusive pain
crisis. Place the steps of an abdominal assessment in order.
1)Have the patient lie down in a supine position.2)Inspect abdomen for size and
shape.3)Auscultate for bowel sounds in all four quadrants.4)Percuss the abdomen
working down from the costal margins.5)Lightly palpate the abdomen for
tenderness, muscle tone, and turgor.6)Palpate deeply from the lower quadrants
upward to the costal margins.
, 8. The nurse is preparing to administer a blood transfusion to a 5-year-old patient
with acute splenic sequestration. Which step(s) should be included during the
preparation and administration process? (Select all that apply.) Use a two-person
verification process to verify the patient and blood component., Follow institution
protocol for blood transfusion administration and management.
9. The nurse is reviewing laboratory results for a patient with sickle cell anemia
presenting with splenic sequestration. Which laboratory result(s) would the nurse
expect to be elevated? (Select all that apply.) Reticulocyte count, Erythrocyte
sedimentation rate, Bilirubin
10. A patient with sickle cell anemia who was admitted in vaso-occlusive crisis for leg
pain reports stomach pain and is guarding her left side. Which assessment(s) should
the nurse perform on this patient? (Select all that apply.) Observation of level of
consciousness, Inspection of skin color and temperature, Auscultation of heart and
lungs, Measurement of vital signs
SBAR Report
S
- Brittany Long is a 5-year-old patient receiving a blood transfusion, IVfluids, and
pain medication for management of acute splenic sequestration
B
- The parent states the patient had been complaining of right lower leg pain over the
last 2 days
- Brittany Long has a history of sickle cell disease, diagnosed at 6 months old
A
- Brittany was rating her pain at a 6/10 using the FACES scale. Spleen was palpated
and noticed to be enlarged
- Spleen was palpated and noticed to be enlarged
R
- Update the provider with the clinical status following the transfusion and for any
additional follow-up that is required
- Monitor administration of PRBCs and monitor patient for any signs of transfusion
reaction
