Critical Care- NCLEX Test Questions with 100% Verified Answers
1. The nurse is assisting with Vital signs
caring for a client who will re-
ceive a unit of blood. Just be-
fore the infusion, it is most im- Rationale: A change in the vital signs may
portant for the nurse to check indicate that a transfusion reaction is oc-
which item? curring. The nurse assesses the client's vi-
tal signs before the procedure to obtain a
baseline every 15 minutes for the first half
hour after beginning the transfusion and
every half hour thereafter. Skin color, oxy-
gen saturation, and most recent hematocrit
may be checked but are not the most im-
portant.
2. A client who is receiving Transfusion reaction
a blood transfusion pushes
the call light for the nurse.
When entering the room, the Rationale: The signs and symptoms exhib-
nurse notes that the client is ited by the client are consistent with a trans-
flushed, dyspneic, and com- fusion reaction. With bacteremia, the client
plaining of generalized itch- would have a fever, which is not part of
ing. How should the nurse the clinical picture presented. With fluid (cir-
correctly interpret these find- culatory) overload, the client would have
ings? crackles in addition to dyspnea. There is no
correlation between the signs mentioned in
the question and hypovolemic shock. The
signs identified in the question are indica-
tive of an allergic reaction, which is one type
of blood transfusion reaction.
3. A client who was receiving a The blood bank
blood transfusion has experi-
enced a transfusion reaction.
The nurse sends the blood Rationale: The nurse prepares to return the
bag that was used for the blood transfusion bag containing any re-
client to which area? maining blood to the blood bank. This al-
lows the blood bank to complete any fol-
low-up testing procedures that are needed
after a transfusion reaction has been doc-
, Critical Care- NCLEX Test Questions with 100% Verified Answers
umented. The remaining options are incor-
rect.
4. The nurse takes a client's tem- The blood will be held, and the primary
perature before giving a blood health care provider (PHCP) will be notified.
transfusion. The temperature
is 100° F (37.7° C) orally. The
nurse reports the finding to Rationale: If the client has a temperature of
the registered nurse (RN) and 100° F (37.7° C) or more, the unit of blood
anticipates that which action should be held until the primary health care
will take place? provider (PHCP) is notified and has the op-
portunity to give further prescriptions. The
other options are incorrect actions.
5. The nurse is doing a routine Infiltration
assessment of a client's pe-
ripheral intravenous (IV) site.
The nurse notes that the site Rationale: An infiltrated IV is one that has
is cool, pale, and swollen and dislodged from the vein and is lying in sub-
that the IV has stopped run- cutaneous tissue. The pallor, coolness, and
ning. The nurse determines swelling are the result of IV fluid being de-
that which has probably oc- posited into the subcutaneous tissue. When
curred? the pressure in the tissues exceeds the
pressure in the tubing, the flow of the IV
solution will stop. The other options identify
complications that are likely to be accom-
panied by warmth at the site rather than
coolness.
6. The nurse is checking the in- Phlebitis of the vein
sertion site of a peripheral
intravenous (IV) catheter. The
nurse notes the site to be Rationale: Phlebitis at an IV site results in
reddened, warm, painful, and discomfort at the site and redness, warmth,
slightly edematous in the area and swelling proximal to the IV catheter.
of the vein proximal to the IV The IV catheter should be removed, and a
catheter. The nurse interprets new IV line should be inserted at a different
that this is likely the result of site. The remaining options are incorrect;
which?
, Critical Care- NCLEX Test Questions with 100% Verified Answers
the signs and symptoms in the question are
not associated with these conditions.
7. The nurse has been instructed Sterile 2 × 2 gauze
to remove an intravenous (IV)
line. The nurse removes the
catheter by withdrawing the Rationale: A dry, sterile dressing such as
catheter while applying pres- sterile 2 × 2 gauze is used to apply pres-
sure to the site with which sure to the site while the catheter is dis-
item? continued and removed. This material is ab-
sorbent, sterile, and nonirritating to the site.
A Band-Aid may be used to cover the site
after hemostasis has occurred. An alcohol
swab or Betadine would irritate the opened
puncture site and would not stop the blood
flow.
8. A client is going to be trans- 15 minutes
fused with a unit of packed
red blood cells (PRBCs). The
nurse understands that it is Rationale: The nurse must remain with the
necessary to remain with the client for the first 15 minutes of a transfu-
client for what time period af- sion, which is the most likely time that a
ter the transfusion is started? transfusion reaction will occur. This enables
the nurse to detect a reaction and intervene
quickly. The nurse engages in safe nursing
practice by obtaining coverage for the other
clients during this time. Five minutes is too
short of a time period, while 30 and 45
minutes are lengthy time periods.
9. The nurse is assisting with Chills, itching, or rash
caring for a client who is
receiving a unit of packed
red blood cells (PRBCs). The Rationale: The client is told to report chills,
nurse should tell the client itching, or rash immediately, because these
that it is most important to re- could be signs of a possible transfusion
port which sign(s) immediate- reaction. Mild discomfort at the catheter site
ly? may be indicative of a problem, or it could
, Critical Care- NCLEX Test Questions with 100% Verified Answers
result from the size of the IV catheter re-
quired to infuse the blood product. Sore
throat, earache, sleepiness, and fatigue are
unrelated to a transfusion reaction.
10. The nurse is assisting with A decrease in oozing from puncture sites
caring for a client who has and gums
received a transfusion of
platelets. The nurse deter-
mines that the client is bene- Rationale: Platelets are necessary for prop-
fiting most from this therapy if er blood clotting. The client with insuf-
the client exhibits which find- ficient platelets may exhibit frank bleed-
ing? ing or the oozing of blood from puncture
sites, wounds, and mucous membranes.
The client's temperature would decline to
normal after the infusion of granulocytes
if those transfused cells were then instru-
mental in fighting infection in the body. In-
creased hemoglobin and hematocrit levels
would be seen when the client has received
a transfusion of red blood cells.
11. A mother calls a neighbor- Call the poison control center.
hood nurse and tells the nurse
that her 3-year-old child has
just ingested liquid furniture Rationale: If a suspected poisoning occurs,
polish. Which action should the poison control center should be con-
the nurse instruct the mother tacted immediately. The nurse can assist
to take first? the mother with contacting the poison con-
trol center. Vomiting should not be induced
without instructions from the poison con-
trol center. Inducing vomiting is not done if
the client is unconscious or the substance
ingested is a strong corrosive or petrole-
um product. Bringing the child to the emer-
gency department or calling an ambulance
would delay treatment. The poison control
center may advise the mother to bring the
child to the emergency department; if this is
1. The nurse is assisting with Vital signs
caring for a client who will re-
ceive a unit of blood. Just be-
fore the infusion, it is most im- Rationale: A change in the vital signs may
portant for the nurse to check indicate that a transfusion reaction is oc-
which item? curring. The nurse assesses the client's vi-
tal signs before the procedure to obtain a
baseline every 15 minutes for the first half
hour after beginning the transfusion and
every half hour thereafter. Skin color, oxy-
gen saturation, and most recent hematocrit
may be checked but are not the most im-
portant.
2. A client who is receiving Transfusion reaction
a blood transfusion pushes
the call light for the nurse.
When entering the room, the Rationale: The signs and symptoms exhib-
nurse notes that the client is ited by the client are consistent with a trans-
flushed, dyspneic, and com- fusion reaction. With bacteremia, the client
plaining of generalized itch- would have a fever, which is not part of
ing. How should the nurse the clinical picture presented. With fluid (cir-
correctly interpret these find- culatory) overload, the client would have
ings? crackles in addition to dyspnea. There is no
correlation between the signs mentioned in
the question and hypovolemic shock. The
signs identified in the question are indica-
tive of an allergic reaction, which is one type
of blood transfusion reaction.
3. A client who was receiving a The blood bank
blood transfusion has experi-
enced a transfusion reaction.
The nurse sends the blood Rationale: The nurse prepares to return the
bag that was used for the blood transfusion bag containing any re-
client to which area? maining blood to the blood bank. This al-
lows the blood bank to complete any fol-
low-up testing procedures that are needed
after a transfusion reaction has been doc-
, Critical Care- NCLEX Test Questions with 100% Verified Answers
umented. The remaining options are incor-
rect.
4. The nurse takes a client's tem- The blood will be held, and the primary
perature before giving a blood health care provider (PHCP) will be notified.
transfusion. The temperature
is 100° F (37.7° C) orally. The
nurse reports the finding to Rationale: If the client has a temperature of
the registered nurse (RN) and 100° F (37.7° C) or more, the unit of blood
anticipates that which action should be held until the primary health care
will take place? provider (PHCP) is notified and has the op-
portunity to give further prescriptions. The
other options are incorrect actions.
5. The nurse is doing a routine Infiltration
assessment of a client's pe-
ripheral intravenous (IV) site.
The nurse notes that the site Rationale: An infiltrated IV is one that has
is cool, pale, and swollen and dislodged from the vein and is lying in sub-
that the IV has stopped run- cutaneous tissue. The pallor, coolness, and
ning. The nurse determines swelling are the result of IV fluid being de-
that which has probably oc- posited into the subcutaneous tissue. When
curred? the pressure in the tissues exceeds the
pressure in the tubing, the flow of the IV
solution will stop. The other options identify
complications that are likely to be accom-
panied by warmth at the site rather than
coolness.
6. The nurse is checking the in- Phlebitis of the vein
sertion site of a peripheral
intravenous (IV) catheter. The
nurse notes the site to be Rationale: Phlebitis at an IV site results in
reddened, warm, painful, and discomfort at the site and redness, warmth,
slightly edematous in the area and swelling proximal to the IV catheter.
of the vein proximal to the IV The IV catheter should be removed, and a
catheter. The nurse interprets new IV line should be inserted at a different
that this is likely the result of site. The remaining options are incorrect;
which?
, Critical Care- NCLEX Test Questions with 100% Verified Answers
the signs and symptoms in the question are
not associated with these conditions.
7. The nurse has been instructed Sterile 2 × 2 gauze
to remove an intravenous (IV)
line. The nurse removes the
catheter by withdrawing the Rationale: A dry, sterile dressing such as
catheter while applying pres- sterile 2 × 2 gauze is used to apply pres-
sure to the site with which sure to the site while the catheter is dis-
item? continued and removed. This material is ab-
sorbent, sterile, and nonirritating to the site.
A Band-Aid may be used to cover the site
after hemostasis has occurred. An alcohol
swab or Betadine would irritate the opened
puncture site and would not stop the blood
flow.
8. A client is going to be trans- 15 minutes
fused with a unit of packed
red blood cells (PRBCs). The
nurse understands that it is Rationale: The nurse must remain with the
necessary to remain with the client for the first 15 minutes of a transfu-
client for what time period af- sion, which is the most likely time that a
ter the transfusion is started? transfusion reaction will occur. This enables
the nurse to detect a reaction and intervene
quickly. The nurse engages in safe nursing
practice by obtaining coverage for the other
clients during this time. Five minutes is too
short of a time period, while 30 and 45
minutes are lengthy time periods.
9. The nurse is assisting with Chills, itching, or rash
caring for a client who is
receiving a unit of packed
red blood cells (PRBCs). The Rationale: The client is told to report chills,
nurse should tell the client itching, or rash immediately, because these
that it is most important to re- could be signs of a possible transfusion
port which sign(s) immediate- reaction. Mild discomfort at the catheter site
ly? may be indicative of a problem, or it could
, Critical Care- NCLEX Test Questions with 100% Verified Answers
result from the size of the IV catheter re-
quired to infuse the blood product. Sore
throat, earache, sleepiness, and fatigue are
unrelated to a transfusion reaction.
10. The nurse is assisting with A decrease in oozing from puncture sites
caring for a client who has and gums
received a transfusion of
platelets. The nurse deter-
mines that the client is bene- Rationale: Platelets are necessary for prop-
fiting most from this therapy if er blood clotting. The client with insuf-
the client exhibits which find- ficient platelets may exhibit frank bleed-
ing? ing or the oozing of blood from puncture
sites, wounds, and mucous membranes.
The client's temperature would decline to
normal after the infusion of granulocytes
if those transfused cells were then instru-
mental in fighting infection in the body. In-
creased hemoglobin and hematocrit levels
would be seen when the client has received
a transfusion of red blood cells.
11. A mother calls a neighbor- Call the poison control center.
hood nurse and tells the nurse
that her 3-year-old child has
just ingested liquid furniture Rationale: If a suspected poisoning occurs,
polish. Which action should the poison control center should be con-
the nurse instruct the mother tacted immediately. The nurse can assist
to take first? the mother with contacting the poison con-
trol center. Vomiting should not be induced
without instructions from the poison con-
trol center. Inducing vomiting is not done if
the client is unconscious or the substance
ingested is a strong corrosive or petrole-
um product. Bringing the child to the emer-
gency department or calling an ambulance
would delay treatment. The poison control
center may advise the mother to bring the
child to the emergency department; if this is
