NUR 2960 NCLEX-RN EXAM P a g e | 1
NUR 2960 NCLEX-RN EXAM 2026 UPDATED
EXAM 4 BUNDLE PRACTICE QUESTIONS
ANSWERED| 3 VERSIONS|GUARANTEED
SUCCESS| SCORE A QUESTIONS AND
ANSWERS ALREADY GRADED A+. 100%
Verified Solutions | Updated Per Latest
Guidelines | Graded A+
After receiving 75 mL of packed red blood cells (PRBCs), a client complains of chills and low back pain.
Which action would the nurse take first?
1.Check the client's temperature.
2. Stop the client's infusion of PRBCs.
3. Cover the client with a warm blanket.
4.Take the client's blood pressure and pulse. –
P a g e 1 | 100
, NUR 2960 NCLEX-RN EXAM P a g e | 2
Correct Answer :2. Stop the client's infusion of PRBCs.
The client's symptoms suggest a transfusion reaction, and the nurse's initial action would be to stop
infusing PRBCs and infuse normal saline. The nurse will send the blood bag to the laboratory for
hemolysis testing. The other actions are also appropriate, once the transfusion has been stopped.
Chills and fever may also occur with a transfusion reaction, and the temperature should be assessed
and the client may be covered with a warmed blanket for comfort. Hypotension and tachycardia may
occur with transfusion reaction and the nurse should check the blood pressure and pulse.
When a client who is receiving a transfusion of packed red blood cells (PRBCs) after cardiac surgery
experiences chest discomfort, chills, and anxiety, which action by the nurse is a priority?
1. Administer nitroglycerin.
2. Monitor the client's vital signs.
3. Stop the transfusion and administer normal saline.
4. Ask the client to describe the pain using a 0 to 10 scale –
Correct Answer :3. Stop the transfusion and administer normal saline.
The chest discomfort and anxiety may indicate an acute hemolytic reaction to the transfusion; the
nurse's first action would be to stop the transfusion and administer normal saline to improve renal
perfusion and prevent acute kidney injury secondary to hemolysis. Nitroglycerin may need to be
administered if the client is experiencing angina, but the first action when a hemolytic reaction is
suspected would be to stop the transfusion and infuse saline. Monitoring the vital signs is important,
but it would be done after stopping the transfusion to prevent ongoing exposure to the PRBCs.
Asking the client to further describe symptoms is needed but not until risk for hemolysis is decreased
by stopping the transfusion.
Which action would the nurse take when administering a transfusion of 2 units of packed red blood
cells (PRBCs) to a client?
P a g e 2 | 100
, NUR 2960 NCLEX-RN EXAM P a g e | 3
1. Infuse lactated Ringer's solution with the PRBCs.
2. Warm the blood to 98°F (36.7°C) to prevent chills.
3. Infuse the blood at a slow rate during the first 15 minutes.
4. Draw blood samples from the client after each unit is transfused –
Correct Answer :3. Infuse the blood at a slow rate during the first 15 minutes.
A slow rate provides time to recognize a reaction that is developing before too much blood is
administered. Normal saline may be infused with blood, but lactated Ringer's solution will cause red
blood cell hemolysis. Blood is not warmed to 98°F (36.7°C) to prevent chills; this could cause clotting
and hemolysis. Drawing blood samples from the client after each unit is transfused is not necessary.
A platelet transfusion is to be administered to a child with acute lymphocytic leukemia. Which step
would the nurse do first?
1. Administer the platelets rapidly through the intravenous (IV) line.
2. Set the intravenous (IV) pump to run for 8 hours.
3. Flush the intravenous (IV) line with a dextrose solution.
4. Check the vital signs every 2 hours during the transfusion. –
Correct Answer :1. Administer the platelets rapidly through the intravenous (IV) line.
Platelets are fragile and should be administered as quickly as possible, within 1 hour, or as fast as the
child can tolerate the infusion. There are minimal numbers of red blood cells (RBCs) and white blood
cells contained within the infusion, which reduces the risk of a severe reaction. Platelets must be
infused within 1 hour. They may be infused as rapidly as the child's cardiovascular status will tolerate. A
dextrose solution is not appropriate for flushing a blood derivative line because it may cause hemolysis
of RBCs. Two hours is too long an interval between checks of the child's vital signs. Vital signs should
be obtained before the infusion, 15 minutes after initiation of the infusion, and at the end of the
infusion.
P a g e 3 | 100
, NUR 2960 NCLEX-RN EXAM P a g e | 4
For which condition is fresh frozen plasma (FFP) ordered ?
1.Thrombocytopenia
2.Oxygen deficiency
3.Clotting factor deficiency
4. Low hemoglobin –
Correct Answer :3.Clotting factor deficiency
FFP is an unconcentrated form of blood plasma containing all of the clotting factors except platelets.
It can be used to supplement red blood cells (RBCs) when other blood products are not available or to
correct a bleeding problem of unknown cause. Thrombocytopenia is a condition of low platelet count
and is not treated with FFP. An oxygen deficiency and low hemoglobin may be improved indirectly
with FFP, but it is not a definitive treatment.
Which action would the nurse take first when a client who is receiving a blood transfusion develops
fever, chills, and low back pain?
1. Stop the blood transfusion and infuse saline.
2Administer the prescribed antipyretic.
3Obtain a prescription for an antihistamine.
4Notify the blood bank about the symptoms
- Correct Answer :1. Stop the blood transfusion and infuse saline.
Fever, chills, and low back pain indicate an acute hemolytic reaction, which is potentially life
threatening; discontinuing the transfusion immediately and infusing saline limits kidney damage.
Although the client has a fever, administering an antipyretic before stopping the transfusion would
allow the transfusion reaction to continue. The client's safety must be addressed first. Obtaining a
prescription for an antihistamine may be done after stopping the transfusion and infusing saline.
Although the blood bank generally is notified if a reaction occurs, this would be done after stopping
the transfusion.
P a g e 4 | 100
NUR 2960 NCLEX-RN EXAM 2026 UPDATED
EXAM 4 BUNDLE PRACTICE QUESTIONS
ANSWERED| 3 VERSIONS|GUARANTEED
SUCCESS| SCORE A QUESTIONS AND
ANSWERS ALREADY GRADED A+. 100%
Verified Solutions | Updated Per Latest
Guidelines | Graded A+
After receiving 75 mL of packed red blood cells (PRBCs), a client complains of chills and low back pain.
Which action would the nurse take first?
1.Check the client's temperature.
2. Stop the client's infusion of PRBCs.
3. Cover the client with a warm blanket.
4.Take the client's blood pressure and pulse. –
P a g e 1 | 100
, NUR 2960 NCLEX-RN EXAM P a g e | 2
Correct Answer :2. Stop the client's infusion of PRBCs.
The client's symptoms suggest a transfusion reaction, and the nurse's initial action would be to stop
infusing PRBCs and infuse normal saline. The nurse will send the blood bag to the laboratory for
hemolysis testing. The other actions are also appropriate, once the transfusion has been stopped.
Chills and fever may also occur with a transfusion reaction, and the temperature should be assessed
and the client may be covered with a warmed blanket for comfort. Hypotension and tachycardia may
occur with transfusion reaction and the nurse should check the blood pressure and pulse.
When a client who is receiving a transfusion of packed red blood cells (PRBCs) after cardiac surgery
experiences chest discomfort, chills, and anxiety, which action by the nurse is a priority?
1. Administer nitroglycerin.
2. Monitor the client's vital signs.
3. Stop the transfusion and administer normal saline.
4. Ask the client to describe the pain using a 0 to 10 scale –
Correct Answer :3. Stop the transfusion and administer normal saline.
The chest discomfort and anxiety may indicate an acute hemolytic reaction to the transfusion; the
nurse's first action would be to stop the transfusion and administer normal saline to improve renal
perfusion and prevent acute kidney injury secondary to hemolysis. Nitroglycerin may need to be
administered if the client is experiencing angina, but the first action when a hemolytic reaction is
suspected would be to stop the transfusion and infuse saline. Monitoring the vital signs is important,
but it would be done after stopping the transfusion to prevent ongoing exposure to the PRBCs.
Asking the client to further describe symptoms is needed but not until risk for hemolysis is decreased
by stopping the transfusion.
Which action would the nurse take when administering a transfusion of 2 units of packed red blood
cells (PRBCs) to a client?
P a g e 2 | 100
, NUR 2960 NCLEX-RN EXAM P a g e | 3
1. Infuse lactated Ringer's solution with the PRBCs.
2. Warm the blood to 98°F (36.7°C) to prevent chills.
3. Infuse the blood at a slow rate during the first 15 minutes.
4. Draw blood samples from the client after each unit is transfused –
Correct Answer :3. Infuse the blood at a slow rate during the first 15 minutes.
A slow rate provides time to recognize a reaction that is developing before too much blood is
administered. Normal saline may be infused with blood, but lactated Ringer's solution will cause red
blood cell hemolysis. Blood is not warmed to 98°F (36.7°C) to prevent chills; this could cause clotting
and hemolysis. Drawing blood samples from the client after each unit is transfused is not necessary.
A platelet transfusion is to be administered to a child with acute lymphocytic leukemia. Which step
would the nurse do first?
1. Administer the platelets rapidly through the intravenous (IV) line.
2. Set the intravenous (IV) pump to run for 8 hours.
3. Flush the intravenous (IV) line with a dextrose solution.
4. Check the vital signs every 2 hours during the transfusion. –
Correct Answer :1. Administer the platelets rapidly through the intravenous (IV) line.
Platelets are fragile and should be administered as quickly as possible, within 1 hour, or as fast as the
child can tolerate the infusion. There are minimal numbers of red blood cells (RBCs) and white blood
cells contained within the infusion, which reduces the risk of a severe reaction. Platelets must be
infused within 1 hour. They may be infused as rapidly as the child's cardiovascular status will tolerate. A
dextrose solution is not appropriate for flushing a blood derivative line because it may cause hemolysis
of RBCs. Two hours is too long an interval between checks of the child's vital signs. Vital signs should
be obtained before the infusion, 15 minutes after initiation of the infusion, and at the end of the
infusion.
P a g e 3 | 100
, NUR 2960 NCLEX-RN EXAM P a g e | 4
For which condition is fresh frozen plasma (FFP) ordered ?
1.Thrombocytopenia
2.Oxygen deficiency
3.Clotting factor deficiency
4. Low hemoglobin –
Correct Answer :3.Clotting factor deficiency
FFP is an unconcentrated form of blood plasma containing all of the clotting factors except platelets.
It can be used to supplement red blood cells (RBCs) when other blood products are not available or to
correct a bleeding problem of unknown cause. Thrombocytopenia is a condition of low platelet count
and is not treated with FFP. An oxygen deficiency and low hemoglobin may be improved indirectly
with FFP, but it is not a definitive treatment.
Which action would the nurse take first when a client who is receiving a blood transfusion develops
fever, chills, and low back pain?
1. Stop the blood transfusion and infuse saline.
2Administer the prescribed antipyretic.
3Obtain a prescription for an antihistamine.
4Notify the blood bank about the symptoms
- Correct Answer :1. Stop the blood transfusion and infuse saline.
Fever, chills, and low back pain indicate an acute hemolytic reaction, which is potentially life
threatening; discontinuing the transfusion immediately and infusing saline limits kidney damage.
Although the client has a fever, administering an antipyretic before stopping the transfusion would
allow the transfusion reaction to continue. The client's safety must be addressed first. Obtaining a
prescription for an antihistamine may be done after stopping the transfusion and infusing saline.
Although the blood bank generally is notified if a reaction occurs, this would be done after stopping
the transfusion.
P a g e 4 | 100
