DETAILED ANSWERS|LATEST
UPDATE!!!2025/2026|GUARANTEED
856. A client had a 100 mL bag of 5% dextrose in 0.9% sodium chloride hung at 1500. The
nurse making rounds at 1545 finds that the client is complaining of a pounding headache
and is dyspneic, experiencing chills, and apprehensive, with an increased pulse rate. The
intravenous bag (IV) has 400 mL remaining. The nurse should take which action FIRST?
1. Slow the IV infusion
2. Sit the client up in bed
3. Remove the IV catheter
4. Call the primary health care provider (PHCP) - ANSWER ANSWER: 1
Rationale: the client's symptoms are compatible with circulatory overload. This may be
verified by noting that 600mL has been infused in the course of 45 minutes. The first action
of the nurse is to slow the infusion. Other actions may be followed in rapid sequence. The
nurse may elevate the head of the bed to aid in the client's breathing if necessary. The nurse
also notifies the PCHP. the IV catheter is not removed; it may be needed for the
administration of medications to resolve the complication.
857. Packed red blood cells have been prescribed for a female client with anemia who has a
hemoglobin level of 7.6 g/dL (76 mol/L) and a hematocrit level of 30% (0.30). The nurse
takes the client's temperature before the blood transfusion and records 100.6 degrees
Fahrenheit (38.1 degrees Celsius) orally. Which action should the nurse take?
1. Begin the transfusion as prescribed
2. Administer an antihistamine and begin the transfusion
3. Administer 2 tablets of acetaminophen
1
, 4. Delay hanging the blood and notify the primary health care provider (PHCP) -
ANSWER ANSWER: 4
Rationale: If the client has a temperature higher than 100 degrees F, the unit of blood should
not be hung until the PHCP is notified and has the opportunity to give further instructions.
The PHCP will likely prescribe that the blood be administered regardless of the temperature
or may instruct the nurse to administer prescribed acetaminophen and wait until the
temperature has decreased before administration, but the decision is not within the nurse's
scope of practice to make. The nurse needs a PHCPs prescription to administer medication
to the client.
858. The nurse is caring for a client experiencing acute lower gastrointestinal bleeding. In
developing the plan of care, which priority problem should the nurse assign to this client?
1. deficient fluid volume related to acute blood loss
2. risk for aspiration related to acute bleeding in the GI tract
3. risk for infection related to acute disease process and medications
4. Imbalanced nutrition, less than body requirements, related to lack of nutrients and
increased metabolism - ANSWER ANSWER 1
Rationale: the priority problem for the client with a cute gastrointestinal bleeding among
these options is deficient fluid volume related to acute blood loss. This state can result in
decreased cardiac output and hypovolemic shock. Although nutrition is a problem, fluid
volume deficit is more of a priority. The client is at risk for aspiration and infection, but these
are not actual problems at this point in time.
859. The nurse is assessing the functioning of a chest tube drainage system in a client with a
chest injury who has just returned from the recovery room following a thoracotomy with
wedge resection. SELECT ALL THAT APPLY
1. Excessive Bubbling in the water seal chamber
2. Vigorous bubbling in the suction control chamber
3. Drainage system maintained below the client's chest
2
UPDATE!!!2025/2026|GUARANTEED
856. A client had a 100 mL bag of 5% dextrose in 0.9% sodium chloride hung at 1500. The
nurse making rounds at 1545 finds that the client is complaining of a pounding headache
and is dyspneic, experiencing chills, and apprehensive, with an increased pulse rate. The
intravenous bag (IV) has 400 mL remaining. The nurse should take which action FIRST?
1. Slow the IV infusion
2. Sit the client up in bed
3. Remove the IV catheter
4. Call the primary health care provider (PHCP) - ANSWER ANSWER: 1
Rationale: the client's symptoms are compatible with circulatory overload. This may be
verified by noting that 600mL has been infused in the course of 45 minutes. The first action
of the nurse is to slow the infusion. Other actions may be followed in rapid sequence. The
nurse may elevate the head of the bed to aid in the client's breathing if necessary. The nurse
also notifies the PCHP. the IV catheter is not removed; it may be needed for the
administration of medications to resolve the complication.
857. Packed red blood cells have been prescribed for a female client with anemia who has a
hemoglobin level of 7.6 g/dL (76 mol/L) and a hematocrit level of 30% (0.30). The nurse
takes the client's temperature before the blood transfusion and records 100.6 degrees
Fahrenheit (38.1 degrees Celsius) orally. Which action should the nurse take?
1. Begin the transfusion as prescribed
2. Administer an antihistamine and begin the transfusion
3. Administer 2 tablets of acetaminophen
1
, 4. Delay hanging the blood and notify the primary health care provider (PHCP) -
ANSWER ANSWER: 4
Rationale: If the client has a temperature higher than 100 degrees F, the unit of blood should
not be hung until the PHCP is notified and has the opportunity to give further instructions.
The PHCP will likely prescribe that the blood be administered regardless of the temperature
or may instruct the nurse to administer prescribed acetaminophen and wait until the
temperature has decreased before administration, but the decision is not within the nurse's
scope of practice to make. The nurse needs a PHCPs prescription to administer medication
to the client.
858. The nurse is caring for a client experiencing acute lower gastrointestinal bleeding. In
developing the plan of care, which priority problem should the nurse assign to this client?
1. deficient fluid volume related to acute blood loss
2. risk for aspiration related to acute bleeding in the GI tract
3. risk for infection related to acute disease process and medications
4. Imbalanced nutrition, less than body requirements, related to lack of nutrients and
increased metabolism - ANSWER ANSWER 1
Rationale: the priority problem for the client with a cute gastrointestinal bleeding among
these options is deficient fluid volume related to acute blood loss. This state can result in
decreased cardiac output and hypovolemic shock. Although nutrition is a problem, fluid
volume deficit is more of a priority. The client is at risk for aspiration and infection, but these
are not actual problems at this point in time.
859. The nurse is assessing the functioning of a chest tube drainage system in a client with a
chest injury who has just returned from the recovery room following a thoracotomy with
wedge resection. SELECT ALL THAT APPLY
1. Excessive Bubbling in the water seal chamber
2. Vigorous bubbling in the suction control chamber
3. Drainage system maintained below the client's chest
2
