CAI Quiz 6 with actual answers 2025.
A nurse is monitoring a client who is receiving a blood transfusion.
Which of the following findings indicates an allergic transfusion reaction?
Blood pressure 184/92 mm Hg.
Generalized urticaria.
Distended jugular veins.
Bilateral flank pain. - ANSWER: • Generalized urticaria.
The nurse should recognize urticaria as an indicator of an allergic transfusion reaction.
Other clinical manifestations include itching and signs of anaphylaxis with
bronchospasm.
A client in the emergency department reports back pain and difficulty breathing 15
minutes after a transfusion of packed red blood cells is started. What should the nurse's
first action be?
Obtain a urine specimen to send to the laboratory.
Disconnect the transfusion and infuse normal saline.
Notify the health care provider about the symptoms.
Administer oxygen therapy at a high flowrate. - ANSWER: • Disconnect the transfusion
and infuse normal saline.
The client's symptoms indicate a possible acute hemolytic reaction caused by the
transfusion. The first action should be to disconnect the transfusion and infuse normal
saline. The other actions also are needed but are not the highest priority.
, A nurse suspects anaphylaxis when caring for a client following the initial administration
of an oral antibiotic. Which of the following should be the nurse's priority action?
Administer oxygen.
Prepare equipment for intubation.
Count the respiratory rate.
Insert an IV line. - ANSWER: • Count the respiratory rate.
A nurse remains with a client to observe for any adverse reactions after initiating a
transfusion of packed RBCs. The client becomes apprehensive and tachycardic,
reporting headache and low back pain.
The nurse should recognize that these findings indicate which of the following
transfusion reactions?
Bacterial
Febrile
Hemolytic
Allergic - ANSWER: Hemolytic
In addition to tachycardia, headache, and low back pain, a hemolytic reaction can also
cause fever, chills, hypotension, possible chest pain, and hemoglobinuria.
A postoperative client receiving a transfusion of packed red blood cells develops chills,
fever, headache, and anxiety 35 minutes after the transfusion is started. After stopping
the transfusion, what action should the nurse take?
Draw blood for a new type and crossmatch.
Send a urine specimen to the laboratory.
Give the prescribed PRN diphenhydramine.
Administer PRN acetaminophen (Tylenol). - ANSWER: • Administer PRN
acetaminophen (Tylenol).
A nurse is monitoring a client who is receiving a blood transfusion.
Which of the following findings indicates an allergic transfusion reaction?
Blood pressure 184/92 mm Hg.
Generalized urticaria.
Distended jugular veins.
Bilateral flank pain. - ANSWER: • Generalized urticaria.
The nurse should recognize urticaria as an indicator of an allergic transfusion reaction.
Other clinical manifestations include itching and signs of anaphylaxis with
bronchospasm.
A client in the emergency department reports back pain and difficulty breathing 15
minutes after a transfusion of packed red blood cells is started. What should the nurse's
first action be?
Obtain a urine specimen to send to the laboratory.
Disconnect the transfusion and infuse normal saline.
Notify the health care provider about the symptoms.
Administer oxygen therapy at a high flowrate. - ANSWER: • Disconnect the transfusion
and infuse normal saline.
The client's symptoms indicate a possible acute hemolytic reaction caused by the
transfusion. The first action should be to disconnect the transfusion and infuse normal
saline. The other actions also are needed but are not the highest priority.
, A nurse suspects anaphylaxis when caring for a client following the initial administration
of an oral antibiotic. Which of the following should be the nurse's priority action?
Administer oxygen.
Prepare equipment for intubation.
Count the respiratory rate.
Insert an IV line. - ANSWER: • Count the respiratory rate.
A nurse remains with a client to observe for any adverse reactions after initiating a
transfusion of packed RBCs. The client becomes apprehensive and tachycardic,
reporting headache and low back pain.
The nurse should recognize that these findings indicate which of the following
transfusion reactions?
Bacterial
Febrile
Hemolytic
Allergic - ANSWER: Hemolytic
In addition to tachycardia, headache, and low back pain, a hemolytic reaction can also
cause fever, chills, hypotension, possible chest pain, and hemoglobinuria.
A postoperative client receiving a transfusion of packed red blood cells develops chills,
fever, headache, and anxiety 35 minutes after the transfusion is started. After stopping
the transfusion, what action should the nurse take?
Draw blood for a new type and crossmatch.
Send a urine specimen to the laboratory.
Give the prescribed PRN diphenhydramine.
Administer PRN acetaminophen (Tylenol). - ANSWER: • Administer PRN
acetaminophen (Tylenol).
