NURS 201 Quiz 9 V3 | NURS 201 Medical
Surgical Nursing | Actual Q&A with
Rationale (NURS201 Quiz 9) | West Coast
University
1. A nurse is caring for a client experiencing a sickle cell crisis. Which of the following
interventions should the nurse prioritize to manage the client’s condition?
A. Administering oral iron supplements
B. Restricting fluid intake to prevent pulmonary edema
C. Applying cold compresses to affected joints
D. Providing aggressive intravenous hydration and oxygen therapy
Answer: D
Rationale: During a sickle cell crisis, the primary goals are to promote hemodilution and
ensure adequate tissue perfusion to prevent further infarcts. Intravenous hydration helps
reduce the viscosity of the blood and prevents the sickling of red blood cells. Oxygen
therapy is also essential because sickling increases in a hypoxic environment, leading to
more pain and tissue damage.
2. A client is receiving a unit of packed red blood cells (PRBCs) and reports sudden lower back
pain and chills. What should be the nurse’s first action?
A. Notify the physician and the blood bank
,B. Stop the blood transfusion immediately and disconnect the tubing
C. Administer diphenhydramine as prescribed
D. Slow the rate of infusion and check vital signs
Answer: B
Rationale: Sudden lower back pain, chills, and fever are classic signs of an acute hemolytic
transfusion reaction. The nurse must immediately stop the infusion to prevent further
administration of incompatible blood. After stopping the infusion, the nurse should
maintain the IV line with normal saline using new tubing and then notify the provider.
3. The nurse is providing discharge education for a client newly diagnosed with iron
deficiency anemia. Which instruction should be included regarding iron supplement
administration?
A. Take the supplement with a glass of milk to prevent upset stomach
B. Avoid taking the medication within 2 hours of caffeine
C. Take the supplement with orange juice to enhance absorption
D. Expect stools to become light green or yellow
Answer: C
Rationale: Vitamin C, found in orange juice, significantly enhances the absorption of iron in
the gastrointestinal tract. Clients should be advised that calcium-rich foods like milk and
caffeine can actually inhibit iron absorption and should be avoided at the time of dose. It is
, also important to warn the client that iron supplements usually cause stools to turn dark
green or black, which is a normal finding.
4. A client with HIV has a CD4+ T-cell count of 180 cells/mm3. The nurse understands that this
finding indicates which stage of the disease?
A. Stage 3: Acquired Immunodeficiency Syndrome (AIDS)
B. Stage 2: Chronic HIV infection
C. Stage 1: Acute HIV infection
D. Stage 0: Early HIV infection window period
Answer: A
Rationale: According to the CDC classification, a CD4+ T-cell count below 200 cells/mm3
defines the diagnosis of AIDS (Stage 3). At this stage, the immune system is severely
compromised, making the client highly susceptible to opportunistic infections. Once a client
is diagnosed with Stage 3, they remain in this classification even if their CD4+ count later
improves.
5. Which clinical manifestation is a hallmark sign of Systemic Lupus Erythematosus (SLE) that
the nurse should assess for during the physical examination?
A. A fixed, flat, or raised erythematous rash across the cheeks and bridge of the nose
B. Painless, small red bumps on the palms
C. Symmetrical silver-white scaly plaques on the elbows
Surgical Nursing | Actual Q&A with
Rationale (NURS201 Quiz 9) | West Coast
University
1. A nurse is caring for a client experiencing a sickle cell crisis. Which of the following
interventions should the nurse prioritize to manage the client’s condition?
A. Administering oral iron supplements
B. Restricting fluid intake to prevent pulmonary edema
C. Applying cold compresses to affected joints
D. Providing aggressive intravenous hydration and oxygen therapy
Answer: D
Rationale: During a sickle cell crisis, the primary goals are to promote hemodilution and
ensure adequate tissue perfusion to prevent further infarcts. Intravenous hydration helps
reduce the viscosity of the blood and prevents the sickling of red blood cells. Oxygen
therapy is also essential because sickling increases in a hypoxic environment, leading to
more pain and tissue damage.
2. A client is receiving a unit of packed red blood cells (PRBCs) and reports sudden lower back
pain and chills. What should be the nurse’s first action?
A. Notify the physician and the blood bank
,B. Stop the blood transfusion immediately and disconnect the tubing
C. Administer diphenhydramine as prescribed
D. Slow the rate of infusion and check vital signs
Answer: B
Rationale: Sudden lower back pain, chills, and fever are classic signs of an acute hemolytic
transfusion reaction. The nurse must immediately stop the infusion to prevent further
administration of incompatible blood. After stopping the infusion, the nurse should
maintain the IV line with normal saline using new tubing and then notify the provider.
3. The nurse is providing discharge education for a client newly diagnosed with iron
deficiency anemia. Which instruction should be included regarding iron supplement
administration?
A. Take the supplement with a glass of milk to prevent upset stomach
B. Avoid taking the medication within 2 hours of caffeine
C. Take the supplement with orange juice to enhance absorption
D. Expect stools to become light green or yellow
Answer: C
Rationale: Vitamin C, found in orange juice, significantly enhances the absorption of iron in
the gastrointestinal tract. Clients should be advised that calcium-rich foods like milk and
caffeine can actually inhibit iron absorption and should be avoided at the time of dose. It is
, also important to warn the client that iron supplements usually cause stools to turn dark
green or black, which is a normal finding.
4. A client with HIV has a CD4+ T-cell count of 180 cells/mm3. The nurse understands that this
finding indicates which stage of the disease?
A. Stage 3: Acquired Immunodeficiency Syndrome (AIDS)
B. Stage 2: Chronic HIV infection
C. Stage 1: Acute HIV infection
D. Stage 0: Early HIV infection window period
Answer: A
Rationale: According to the CDC classification, a CD4+ T-cell count below 200 cells/mm3
defines the diagnosis of AIDS (Stage 3). At this stage, the immune system is severely
compromised, making the client highly susceptible to opportunistic infections. Once a client
is diagnosed with Stage 3, they remain in this classification even if their CD4+ count later
improves.
5. Which clinical manifestation is a hallmark sign of Systemic Lupus Erythematosus (SLE) that
the nurse should assess for during the physical examination?
A. A fixed, flat, or raised erythematous rash across the cheeks and bridge of the nose
B. Painless, small red bumps on the palms
C. Symmetrical silver-white scaly plaques on the elbows
