Question 1
A client who is receiving a whole blood transfusion develops chills, fever, and a headache
30 minutes after the transfusion is started. The nurse should recognize these symptoms as
characteristic of what reaction?
A. A mild allergic reaction.
B. A febrile transfusion reaction.
C. An anaphylactic transfusion reaction.
D. An acute hemolytic transfusion reaction.
CORRECT ANSWER
B. A febrile transfusion reaction.
Question 2
The nurse is assessing a client with a ruptured small bowel and determines that the client
has a temperature of 102.8o F. Which assessment finding provides the earliest indication
that the client is experiencing septic shock?
A. Bilateral crackles.
B. Hyperpnea.
C. Mucus production.
D. Weak peripheral pulses.
CORRECT ANSWER
B. Hyperpnea.
1
@THE STUDY VAULT
,Question 3
The nurse is caring for a client with syndrome of inappropriate antidiuretic hormone
(SIADH), which is manifested by which symptoms?
A. Loss of thirst, weight gain.
B. Dependent edema, fever.
C. Polydipsia, polyuria.
D. Hypernatremia, tachypnea.
CORRECT ANSWER
A. Loss of thirst, weight gain.
Question 4
A client is brought to the Emergency Center after a snow-skiing accident. Which
intervention is most important for the nurse to implement?
A. Review the electrocardiogram tracing.
B. Obtain blood for coagulation studies.
C. Apply a warming blanket.
D. Provide heated PO fluids.
CORRECT ANSWER
A. Review the electrocardiogram tracing.
Question 5
Which pathophysiological response supports a client's vomiting experience?
A. Sensory input of noxious stimuli relayed to the cognitive centers is associated with disgust
and illicits vomiting.
B. Response of stimulation of the posterior oropharynx results in reverse peristalsis of the
gastrointestinal tract.
2
@THE STUDY VAULT
, C. Spasmodic reflex of respiratory and gastric movements results from stimulation of the
chemoreceptor trigger zone.
D. Increased gastric and colonic pressures move gastrointestinal contents to the orifice of
least resistance.
CORRECT ANSWER
C. Spasmodic reflex of respiratory and gastric movements results from stimulation of the
chemoreceptor trigger zone.
Question 6
The nurse reviews the complete blood count (CBC) findings of an adolescent with acute
myelogenous leukemia (AML). The hemoglobin is 13.8 g/dl, hematocrit is 36.7%, white
blood cell count is 8,200 mm3, and platelet count is 115,000 mm3. Based on these
findings, what is the priority nursing diagnosis for this client's plan of care?
A. Impaired gas exchange.
B. Risk for infection.
C. Risk for injury.
D. Risk for activity intolerance.
CORRECT ANSWER
C. Risk for injury.
Question 7
Which signs and symptoms are associated with arterial insufficiency?
A. Pallor, intermittent claudication.
B. Pedal edema, brown pigmentation.
C. Blanched skin, lower extremity ulcers.
D. Peripheral neuropathy, cold extremities.
CORRECT ANSWER
3
@THE STUDY VAULT
A client who is receiving a whole blood transfusion develops chills, fever, and a headache
30 minutes after the transfusion is started. The nurse should recognize these symptoms as
characteristic of what reaction?
A. A mild allergic reaction.
B. A febrile transfusion reaction.
C. An anaphylactic transfusion reaction.
D. An acute hemolytic transfusion reaction.
CORRECT ANSWER
B. A febrile transfusion reaction.
Question 2
The nurse is assessing a client with a ruptured small bowel and determines that the client
has a temperature of 102.8o F. Which assessment finding provides the earliest indication
that the client is experiencing septic shock?
A. Bilateral crackles.
B. Hyperpnea.
C. Mucus production.
D. Weak peripheral pulses.
CORRECT ANSWER
B. Hyperpnea.
1
@THE STUDY VAULT
,Question 3
The nurse is caring for a client with syndrome of inappropriate antidiuretic hormone
(SIADH), which is manifested by which symptoms?
A. Loss of thirst, weight gain.
B. Dependent edema, fever.
C. Polydipsia, polyuria.
D. Hypernatremia, tachypnea.
CORRECT ANSWER
A. Loss of thirst, weight gain.
Question 4
A client is brought to the Emergency Center after a snow-skiing accident. Which
intervention is most important for the nurse to implement?
A. Review the electrocardiogram tracing.
B. Obtain blood for coagulation studies.
C. Apply a warming blanket.
D. Provide heated PO fluids.
CORRECT ANSWER
A. Review the electrocardiogram tracing.
Question 5
Which pathophysiological response supports a client's vomiting experience?
A. Sensory input of noxious stimuli relayed to the cognitive centers is associated with disgust
and illicits vomiting.
B. Response of stimulation of the posterior oropharynx results in reverse peristalsis of the
gastrointestinal tract.
2
@THE STUDY VAULT
, C. Spasmodic reflex of respiratory and gastric movements results from stimulation of the
chemoreceptor trigger zone.
D. Increased gastric and colonic pressures move gastrointestinal contents to the orifice of
least resistance.
CORRECT ANSWER
C. Spasmodic reflex of respiratory and gastric movements results from stimulation of the
chemoreceptor trigger zone.
Question 6
The nurse reviews the complete blood count (CBC) findings of an adolescent with acute
myelogenous leukemia (AML). The hemoglobin is 13.8 g/dl, hematocrit is 36.7%, white
blood cell count is 8,200 mm3, and platelet count is 115,000 mm3. Based on these
findings, what is the priority nursing diagnosis for this client's plan of care?
A. Impaired gas exchange.
B. Risk for infection.
C. Risk for injury.
D. Risk for activity intolerance.
CORRECT ANSWER
C. Risk for injury.
Question 7
Which signs and symptoms are associated with arterial insufficiency?
A. Pallor, intermittent claudication.
B. Pedal edema, brown pigmentation.
C. Blanched skin, lower extremity ulcers.
D. Peripheral neuropathy, cold extremities.
CORRECT ANSWER
3
@THE STUDY VAULT
