Detailed Answer Key
BMS Quiz Week 8 Day
1. A nurse is reviewing the laboratory results of an adolescent female client and notes a WBC count of 16,000/mm³
with increased immature neutrophils (bands) and normal monocytes. Which of the following is the appropriate
analysis of the results?
A. An acute infectious process
Rationale: The white blood cell (WBC) count is greatly elevated; however, even more telling is the elevated
neutrophil count, sometimes referred to as a "shift to the left." So, with the combined information
from the elevated WBC count indicating infection or inflammation and the elevated neutrophil
count indicating an acute process, the appropriate analysis is that the client has an acute
infectious process.
B. Neutropenia
Rationale: Neutropenia is a low neutrophil count which places the client at increased risk for infection.
C. Allergic reaction
Rationale: A client who is having an allergic reaction will have increased numbers of eosinophils. These
cells increase during hypersensitivity reactions and serve to neutralize histamine.
D. A resolving inflammatory process
Rationale: The white blood cell (WBC) count is elevated indicating infection. However, when combined with
the elevated bands, sometimes referred to as a "shift to the left," this indicates an acute, rather
than a resolving, process. In a resolving or chronic process, the nurse would expect to see a
greater elevation in the monocytes.
2. A nurse is planning nutritional teaching for a client who is experiencing fatigue due to iron deficiency anemia. Which
of the following foods should the nurse recommend to the client?
A. 1.5 oz raisins
Rationale: The nurse should recommend that the client eat dried fruits, such as raisins, to increase iron
intake. However, a small box (1.5 oz) of raisins contains only 0.81 mg of iron.
B. 8 oz black tea
Rationale: The nurse should recommend the client avoid tea as it contains tannin, a product that inhibits
the absorption of iron.
C. 1 cup canned black beans
Rationale: The nurse should recommend canned black beans as they contain the greatest amount of iron
at 4.56 mg per serving.
D. 8 oz whole milk
Rationale: The nurse should recommend the client avoid drinking milk in conjunction with iron tablets or
iron-rich foods. The calcium in the milk product limits the absorption of the iron. Instead the
nurse could recommend the client take the iron product with orange juice as the ascorbic acid
(vitamin C) contained in the orange juice increases the absorption of iron-rich foods.
Created on:11/23/2022 Page 1
, Detailed Answer Key
BMS Quiz Week 8 Day
3. A nurse remains with a client to observe for any adverse reactions after initiating a transfusion of packed RBCs.
The client becomes apprehensive and tachycardic, reporting headache and low back pain. The nurse should
recognize that these findings indicate which of the following transfusion reactions?
A. Febrile
Rationale: A client having a febrile transfusion reaction exhibits tachycardia along with fever, but not
headache and low back pain.
B. Hemolytic
Rationale: In addition to tachycardia, headache, and low back pain, a hemolytic reaction can also cause
fever, chills, hypotension, possible chest pain, and hemoglobinuria.
C. Allergic
Rationale: A client having an allergic transfusion reaction exhibits tachycardia—in addition to urticaria,
itching, and bronchospasm—without headache or low back pain.
D. Bacterial
Rationale: A client having a bacterial transfusion reaction exhibits tachycardia—in addition to hypotension,
fever, and chills—but not headache and low back pain.
4. A nurse is in a client's room when the client begins having a tonic-clonic seizure. Which of the following actions
should the nurse take first?
A. Turn the client's head to the side.
Rationale: The first action the nurse should take when using the airway, breathing, circulation approach to
client care is to turn the client's head to the side. This action keeps the client's airway clear of
secretion to prevent aspiration.
B. Check the client's motor strength.
Rationale: The nurse should check the client's motor strength as part of a neurovascular assessment
following the seizure; however, there is another action the nurse should take first.
C. Loosen the clothing around the client's waist.
Rationale: The nurse should loosen the clothing around the client's waist to protect the client from injury;
however, there is another action the nurse should take first.
D. Document the time the seizure began.
Rationale: The nurse should document the time the seizure began and ended to provide information to the
provider about the severity of the seizure; however, there is another action the nurse should take
first.
Created on:11/23/2022 Page 2
BMS Quiz Week 8 Day
1. A nurse is reviewing the laboratory results of an adolescent female client and notes a WBC count of 16,000/mm³
with increased immature neutrophils (bands) and normal monocytes. Which of the following is the appropriate
analysis of the results?
A. An acute infectious process
Rationale: The white blood cell (WBC) count is greatly elevated; however, even more telling is the elevated
neutrophil count, sometimes referred to as a "shift to the left." So, with the combined information
from the elevated WBC count indicating infection or inflammation and the elevated neutrophil
count indicating an acute process, the appropriate analysis is that the client has an acute
infectious process.
B. Neutropenia
Rationale: Neutropenia is a low neutrophil count which places the client at increased risk for infection.
C. Allergic reaction
Rationale: A client who is having an allergic reaction will have increased numbers of eosinophils. These
cells increase during hypersensitivity reactions and serve to neutralize histamine.
D. A resolving inflammatory process
Rationale: The white blood cell (WBC) count is elevated indicating infection. However, when combined with
the elevated bands, sometimes referred to as a "shift to the left," this indicates an acute, rather
than a resolving, process. In a resolving or chronic process, the nurse would expect to see a
greater elevation in the monocytes.
2. A nurse is planning nutritional teaching for a client who is experiencing fatigue due to iron deficiency anemia. Which
of the following foods should the nurse recommend to the client?
A. 1.5 oz raisins
Rationale: The nurse should recommend that the client eat dried fruits, such as raisins, to increase iron
intake. However, a small box (1.5 oz) of raisins contains only 0.81 mg of iron.
B. 8 oz black tea
Rationale: The nurse should recommend the client avoid tea as it contains tannin, a product that inhibits
the absorption of iron.
C. 1 cup canned black beans
Rationale: The nurse should recommend canned black beans as they contain the greatest amount of iron
at 4.56 mg per serving.
D. 8 oz whole milk
Rationale: The nurse should recommend the client avoid drinking milk in conjunction with iron tablets or
iron-rich foods. The calcium in the milk product limits the absorption of the iron. Instead the
nurse could recommend the client take the iron product with orange juice as the ascorbic acid
(vitamin C) contained in the orange juice increases the absorption of iron-rich foods.
Created on:11/23/2022 Page 1
, Detailed Answer Key
BMS Quiz Week 8 Day
3. A nurse remains with a client to observe for any adverse reactions after initiating a transfusion of packed RBCs.
The client becomes apprehensive and tachycardic, reporting headache and low back pain. The nurse should
recognize that these findings indicate which of the following transfusion reactions?
A. Febrile
Rationale: A client having a febrile transfusion reaction exhibits tachycardia along with fever, but not
headache and low back pain.
B. Hemolytic
Rationale: In addition to tachycardia, headache, and low back pain, a hemolytic reaction can also cause
fever, chills, hypotension, possible chest pain, and hemoglobinuria.
C. Allergic
Rationale: A client having an allergic transfusion reaction exhibits tachycardia—in addition to urticaria,
itching, and bronchospasm—without headache or low back pain.
D. Bacterial
Rationale: A client having a bacterial transfusion reaction exhibits tachycardia—in addition to hypotension,
fever, and chills—but not headache and low back pain.
4. A nurse is in a client's room when the client begins having a tonic-clonic seizure. Which of the following actions
should the nurse take first?
A. Turn the client's head to the side.
Rationale: The first action the nurse should take when using the airway, breathing, circulation approach to
client care is to turn the client's head to the side. This action keeps the client's airway clear of
secretion to prevent aspiration.
B. Check the client's motor strength.
Rationale: The nurse should check the client's motor strength as part of a neurovascular assessment
following the seizure; however, there is another action the nurse should take first.
C. Loosen the clothing around the client's waist.
Rationale: The nurse should loosen the clothing around the client's waist to protect the client from injury;
however, there is another action the nurse should take first.
D. Document the time the seizure began.
Rationale: The nurse should document the time the seizure began and ended to provide information to the
provider about the severity of the seizure; however, there is another action the nurse should take
first.
Created on:11/23/2022 Page 2
