ACE YOUR 2026/2027 NURS 6512N ADVANCED
HEALTH ASSESSMENT EXAMINATION:
COMPREHENSIVE QUESTIONS AND ANSWERS
GRADED A+
⩥ A client is receiving a unit of packed red blood cells. Before the
transfusion started, the client's blood pressure was 90/50 mm Hg, pulse
rate 100 bpm, respirations 20 breaths/minute, and temperature 98° F
(36.7° C). Fifteen minutes after the transfusion starts, the client's blood
pressure is 92/54 mm Hg, pulse 100 bpm, respirations 18
breaths/minute, and temperature is 101.4° F (38.6° C). The nurse should
first:
a) obtain a prescription for antibiotics.
b) stop the transfusion.
c) raise the head of the bed.
d) offer the client a cool washcloth. Answer: stop the transfusion.
The nurse's first action should be to clamp off the transfusion because
the client is having a transfusion reaction. It is most important that the
client not receive any more blood. Other measures may be appropriate
after the blood has been stopped. The nurse should raise the head of the
bed if the client becomes short of breath. There is no need for antibiotic
therapy for a blood transfusion related to a temperature spike. The nurse
,can provide a cool washcloth for a headache or fever; however, this is
not a priority.
⩥ A client receiving a blood transfusion experiences an acute hemolytic
reaction. Which nursing intervention is the most important?
a) Stop the transfusion, notify the blood bank, and administer
antihistamines.
b) Assess the temperature, blood pressure, and check for blood in the
urine. Then stop the transfusion.
c) Slow the transfusion and monitor the client's vital signs.
d) Stop the transfusion, infuse normal saline solution, and call the
physician.. Answer: Stop the transfusion, infuse normal saline
solution, and call the physician.
When a transfusion reaction occurs, the transfusion should be
immediately stopped, normal saline solution should be infused to
maintain venous access, and the physician and blood bank should be
notified immediately. Other nursing actions include saving the blood bag
and tubing, rechecking the blood type and identification numbers on the
blood tags, monitoring vital signs, obtaining necessary laboratory blood
and urine samples, providing proper documentation, and monitoring and
treating for shock. Because they can cause red blood cell hemolysis,
dextrose solutions should not be infused with blood products.
Antihistamines are administered for a mild allergic reaction, not a
hemolytic reaction
,⩥ A client with pernicious anemia asks why she must take vitamin B12
injections forever. Which is the nurse's best response?
a) "The reason for your vitamin deficiency is an inability to absorb
the vitamin because the stomach is not producing sufficient amounts of
a factor that allows the vitamin to be absorbed."
b) "The reason for your vitamin deficiency is an inability to absorb
the vitamin because the stomach is not producing sufficient acid."
c) "The reason for your vitamin deficiency is an increased
requirement for the vitamin because of rapid red blood cell production."
d) "The reason for your vitamin deficiency is an excessive excretion
of the vitamin because of kidney dysfunction.". Answer: The reason for
your vitamin deficiency is an inability to absorb the vitamin because the
stomach is not producing sufficient amounts of a factor that allows the
vitamin to be absorbed."
Most clients with pernicious anemia have deficient production of
intrinsic factor in the stomach. Intrinsic factor attaches to the vitamin in
the stomach and forms a complex that allows the vitamin to be absorbed
in the small intestine. The stomach is producing enough acid, there is not
an excessive excretion of the vitamin, and there is not a rapid production
of red blood cells in this condition.
⩥ A client comes into the emergency department with extreme fatigue.
He is malnourished and laboratory tests reveal severe anemia. Based on
an understanding of how vitamin and mineral deficiencies are associated
, with anemia, the nurse should specifically ask the client about the intake
of food high in which of the following nutrients?
a) Vitamin K
b) Thiamine, riboflavin, and niacin
c) Vitamins A, E, and C
d) Vitamins B6 and B12, folate, iron, and copper. Answer: Vitamins B6
and B12, folate, iron, and copper
Many vitamin and mineral deficiencies can result in anemia. Intake of
alll of these vitamins and minerals need to be assessed, preferably
through a nutrition assessment. Deficiencies of vitamins A, B6, and C
result in a small cell, microcytic anemia. Folate and vitamin B12
deficiencies result in a large cell, macrocytic anemia. Iron, copper, and
vitamin E deficiencies can also result in anemia. Vitamin K alters
clotting time, but is not associated with anemia
⩥ A client with anemia has been admitted to the medical-surgical unit.
Which assessment findings are characteristic of iron deficiency anemia?
a) Dyspnea, tachycardia, and pallor
b) Itching, rash, and jaundice
c) Nights sweats, weight loss, and diarrhea
d) Nausea, vomiting, and anorexia. Answer: Dyspnea, tachycardia, and
HEALTH ASSESSMENT EXAMINATION:
COMPREHENSIVE QUESTIONS AND ANSWERS
GRADED A+
⩥ A client is receiving a unit of packed red blood cells. Before the
transfusion started, the client's blood pressure was 90/50 mm Hg, pulse
rate 100 bpm, respirations 20 breaths/minute, and temperature 98° F
(36.7° C). Fifteen minutes after the transfusion starts, the client's blood
pressure is 92/54 mm Hg, pulse 100 bpm, respirations 18
breaths/minute, and temperature is 101.4° F (38.6° C). The nurse should
first:
a) obtain a prescription for antibiotics.
b) stop the transfusion.
c) raise the head of the bed.
d) offer the client a cool washcloth. Answer: stop the transfusion.
The nurse's first action should be to clamp off the transfusion because
the client is having a transfusion reaction. It is most important that the
client not receive any more blood. Other measures may be appropriate
after the blood has been stopped. The nurse should raise the head of the
bed if the client becomes short of breath. There is no need for antibiotic
therapy for a blood transfusion related to a temperature spike. The nurse
,can provide a cool washcloth for a headache or fever; however, this is
not a priority.
⩥ A client receiving a blood transfusion experiences an acute hemolytic
reaction. Which nursing intervention is the most important?
a) Stop the transfusion, notify the blood bank, and administer
antihistamines.
b) Assess the temperature, blood pressure, and check for blood in the
urine. Then stop the transfusion.
c) Slow the transfusion and monitor the client's vital signs.
d) Stop the transfusion, infuse normal saline solution, and call the
physician.. Answer: Stop the transfusion, infuse normal saline
solution, and call the physician.
When a transfusion reaction occurs, the transfusion should be
immediately stopped, normal saline solution should be infused to
maintain venous access, and the physician and blood bank should be
notified immediately. Other nursing actions include saving the blood bag
and tubing, rechecking the blood type and identification numbers on the
blood tags, monitoring vital signs, obtaining necessary laboratory blood
and urine samples, providing proper documentation, and monitoring and
treating for shock. Because they can cause red blood cell hemolysis,
dextrose solutions should not be infused with blood products.
Antihistamines are administered for a mild allergic reaction, not a
hemolytic reaction
,⩥ A client with pernicious anemia asks why she must take vitamin B12
injections forever. Which is the nurse's best response?
a) "The reason for your vitamin deficiency is an inability to absorb
the vitamin because the stomach is not producing sufficient amounts of
a factor that allows the vitamin to be absorbed."
b) "The reason for your vitamin deficiency is an inability to absorb
the vitamin because the stomach is not producing sufficient acid."
c) "The reason for your vitamin deficiency is an increased
requirement for the vitamin because of rapid red blood cell production."
d) "The reason for your vitamin deficiency is an excessive excretion
of the vitamin because of kidney dysfunction.". Answer: The reason for
your vitamin deficiency is an inability to absorb the vitamin because the
stomach is not producing sufficient amounts of a factor that allows the
vitamin to be absorbed."
Most clients with pernicious anemia have deficient production of
intrinsic factor in the stomach. Intrinsic factor attaches to the vitamin in
the stomach and forms a complex that allows the vitamin to be absorbed
in the small intestine. The stomach is producing enough acid, there is not
an excessive excretion of the vitamin, and there is not a rapid production
of red blood cells in this condition.
⩥ A client comes into the emergency department with extreme fatigue.
He is malnourished and laboratory tests reveal severe anemia. Based on
an understanding of how vitamin and mineral deficiencies are associated
, with anemia, the nurse should specifically ask the client about the intake
of food high in which of the following nutrients?
a) Vitamin K
b) Thiamine, riboflavin, and niacin
c) Vitamins A, E, and C
d) Vitamins B6 and B12, folate, iron, and copper. Answer: Vitamins B6
and B12, folate, iron, and copper
Many vitamin and mineral deficiencies can result in anemia. Intake of
alll of these vitamins and minerals need to be assessed, preferably
through a nutrition assessment. Deficiencies of vitamins A, B6, and C
result in a small cell, microcytic anemia. Folate and vitamin B12
deficiencies result in a large cell, macrocytic anemia. Iron, copper, and
vitamin E deficiencies can also result in anemia. Vitamin K alters
clotting time, but is not associated with anemia
⩥ A client with anemia has been admitted to the medical-surgical unit.
Which assessment findings are characteristic of iron deficiency anemia?
a) Dyspnea, tachycardia, and pallor
b) Itching, rash, and jaundice
c) Nights sweats, weight loss, and diarrhea
d) Nausea, vomiting, and anorexia. Answer: Dyspnea, tachycardia, and
