NCLEX Critical Care Nurse Question and Answers Graded A+
1. A client receiving a transfusion of packed red A. Septicemia
blood cells begins to vomit. The client's blood
pressure is 90/50 mm Hg from a baseline of occurs with the transfu-
125/78 mm Hg. The client's temperature is 100.8 sion of blood contam-
° F orally from a baseline of 99.2 ° F. The nurse inated with microorgan-
determines that the client may be experiencing isms. Signs include chills,
which complication of a blood transfusion? fever, vomiting, diarrhea,
hypotension, and the de-
A. Septicemia velopment of shock.
B. Hyperkalemia
C. Circulatory overload
D. Delayed transfusion reaction
2. 2. The critical care nurse recognizes that an D. An individually devised
ideal plan for caregiver involvement includes plan to involve caregivers
with care and comfort
A. allowing caregivers at the bedside at preset, measures.
brief intervals.
Rationale: An individual-
B. a caregiver at the bedside at all times. ized plan of care should
be developed for each pa-
C. restriction of visiting in the ICU because the tient and the caregivers.
environment is overwhelming to caregivers. Caregivers should be al-
lowed to assist with care
D. an individually devised plan to involve care- and comfort measures in
givers with care and comfort measures. the ICU if desired.
3. The nurse wants to assess the oxygenation sta- A. Use pulse oximetry
tus of a patient who has been experiencing a B. Send a blood sam-
gastrointestinal bleed. How will the nurse com- ple for arterial blood gas
plete this assessment? Select all that apply. analysis
A. Use pulse oximetry
B. Send a blood sample for arterial blood gas
analysis
C. Auscultate lung sounds
D. Evaluate cardiac rhythm strip
E. Calculate mean arterial pressure
4.
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1. A client receiving a transfusion of packed red A. Septicemia
blood cells begins to vomit. The client's blood
pressure is 90/50 mm Hg from a baseline of occurs with the transfu-
125/78 mm Hg. The client's temperature is 100.8 sion of blood contam-
° F orally from a baseline of 99.2 ° F. The nurse inated with microorgan-
determines that the client may be experiencing isms. Signs include chills,
which complication of a blood transfusion? fever, vomiting, diarrhea,
hypotension, and the de-
A. Septicemia velopment of shock.
B. Hyperkalemia
C. Circulatory overload
D. Delayed transfusion reaction
2. 2. The critical care nurse recognizes that an D. An individually devised
ideal plan for caregiver involvement includes plan to involve caregivers
with care and comfort
A. allowing caregivers at the bedside at preset, measures.
brief intervals.
Rationale: An individual-
B. a caregiver at the bedside at all times. ized plan of care should
be developed for each pa-
C. restriction of visiting in the ICU because the tient and the caregivers.
environment is overwhelming to caregivers. Caregivers should be al-
lowed to assist with care
D. an individually devised plan to involve care- and comfort measures in
givers with care and comfort measures. the ICU if desired.
3. The nurse wants to assess the oxygenation sta- A. Use pulse oximetry
tus of a patient who has been experiencing a B. Send a blood sam-
gastrointestinal bleed. How will the nurse com- ple for arterial blood gas
plete this assessment? Select all that apply. analysis
A. Use pulse oximetry
B. Send a blood sample for arterial blood gas
analysis
C. Auscultate lung sounds
D. Evaluate cardiac rhythm strip
E. Calculate mean arterial pressure
4.
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