Medical Surgical Nursing III Final Questions With
Complete Solutions
A nurse is reviewing the PT, aPTT, and INR laboratory values
for a client who is experiencing an acute episode of
disseminated intravascular coagulation. Which of the following
laboratory results should the nurse expect?
The laboratory values are prolonged
A nurse is assessing a client who is receiving a unit of packed
RBCs. The client appears flushed and reports low back pain.
Which of the following actions is the nurse's priority?
Stop the transfusion
A nurse is assessing a client who is receiving a blood
transfusion. Which of the following findings is a manifestation
of a hemolytic transfusion reaction?
Report of low back pain
A nurse is assessing a client who is receiving one unit of packed
RBCs to treat intraoperative blood loss. The client reports chills
and back pain, and the client's blood pressure is 80/64. Which of
the following actions should the nurse take first?
Stop the infusion of blood
A nurse is assessing a client who is receiving a unit of packed
red blood cells. Which of the following is a manifestation of
acute hemolytic reaction?
The client reports low back pain
,A nurse is administering a unit of RBC 350 mL over 3 hours to a
client who has anemia. The nurse set the IV pump to deliver
how many mL/hr?
117 mL/hr
A nurse is caring for a client who is at risk for shock. Which of
the following findings is the earliest indicator that this
complication is developing?
Narrowing pulse pressure
A nurse is monitoring a client who is receiving a blood
transfusion. Which of the following findings indicates an
allergic transfusion reaction?
Generalized urticaria
A nurse is preparing to administer 0.9% sodium chloride 1,200
mL IV to infuse over 24 hours. The drop factor of the manual IV
tubing is 15 gtt/mL. The nurse should set the manual IV infusion
to deliver how many gtt/min?
13 gtt/min
A nurse is preparing to administer a transfusion of RBCs to a
client who has heart failure. For which of the following
manifestations should the nurse monitor for fluid volume
overload?
Dyspnea
Jugular vein distention
Confusion
, A nurse is preparing to administer blood to a client. Which of
the following actions should the nurse take to identify the client?
Verify the provider's prescription with another RN
Scan the barcode on the client's identification band
Compare the client identification number to the blood
component bag
A nurse is planning to perform a blood transfusion for a client.
Which of the following actions should the nurse plan to take?
check vital signs before transfusion
insert an IV with a 19-gauge needle
check the expiration date of the blood product with a second
nurse
a nurse is preparing to administer an IV fluid bolus of 200 mL
dextrose 5% in water over 30 minutes. The drop factor of the
manual IV tubing is 15 gtt/mL. The nurse should set the manual
IV infusion to deliver how many gtt/min?
100 gtt/min
A nurse is planning care for a client who has leukemia and a
platelet count of 48,000. Which of the following interventions
should the nurse include in the plan?
Test the client's urine and stool for occult blood
A nurse is teaching the parent of a child about administration
guidelines for the human papillomavirus vaccine. Which of the
following information should the nurse include?
Complete Solutions
A nurse is reviewing the PT, aPTT, and INR laboratory values
for a client who is experiencing an acute episode of
disseminated intravascular coagulation. Which of the following
laboratory results should the nurse expect?
The laboratory values are prolonged
A nurse is assessing a client who is receiving a unit of packed
RBCs. The client appears flushed and reports low back pain.
Which of the following actions is the nurse's priority?
Stop the transfusion
A nurse is assessing a client who is receiving a blood
transfusion. Which of the following findings is a manifestation
of a hemolytic transfusion reaction?
Report of low back pain
A nurse is assessing a client who is receiving one unit of packed
RBCs to treat intraoperative blood loss. The client reports chills
and back pain, and the client's blood pressure is 80/64. Which of
the following actions should the nurse take first?
Stop the infusion of blood
A nurse is assessing a client who is receiving a unit of packed
red blood cells. Which of the following is a manifestation of
acute hemolytic reaction?
The client reports low back pain
,A nurse is administering a unit of RBC 350 mL over 3 hours to a
client who has anemia. The nurse set the IV pump to deliver
how many mL/hr?
117 mL/hr
A nurse is caring for a client who is at risk for shock. Which of
the following findings is the earliest indicator that this
complication is developing?
Narrowing pulse pressure
A nurse is monitoring a client who is receiving a blood
transfusion. Which of the following findings indicates an
allergic transfusion reaction?
Generalized urticaria
A nurse is preparing to administer 0.9% sodium chloride 1,200
mL IV to infuse over 24 hours. The drop factor of the manual IV
tubing is 15 gtt/mL. The nurse should set the manual IV infusion
to deliver how many gtt/min?
13 gtt/min
A nurse is preparing to administer a transfusion of RBCs to a
client who has heart failure. For which of the following
manifestations should the nurse monitor for fluid volume
overload?
Dyspnea
Jugular vein distention
Confusion
, A nurse is preparing to administer blood to a client. Which of
the following actions should the nurse take to identify the client?
Verify the provider's prescription with another RN
Scan the barcode on the client's identification band
Compare the client identification number to the blood
component bag
A nurse is planning to perform a blood transfusion for a client.
Which of the following actions should the nurse plan to take?
check vital signs before transfusion
insert an IV with a 19-gauge needle
check the expiration date of the blood product with a second
nurse
a nurse is preparing to administer an IV fluid bolus of 200 mL
dextrose 5% in water over 30 minutes. The drop factor of the
manual IV tubing is 15 gtt/mL. The nurse should set the manual
IV infusion to deliver how many gtt/min?
100 gtt/min
A nurse is planning care for a client who has leukemia and a
platelet count of 48,000. Which of the following interventions
should the nurse include in the plan?
Test the client's urine and stool for occult blood
A nurse is teaching the parent of a child about administration
guidelines for the human papillomavirus vaccine. Which of the
following information should the nurse include?
