ASSESSMENT GUIDE 2025
|MOST COMMON QUESTIONS(THE LATEST QUIZ)
WITH CORRECTLY
VERIFIED ANSWERS|ALREADY A+
GRADED|GUARANTEED PASS
116. Packed red blood cells have been prescribed for a female client with a hemoglobin level of
7.6 g/dL (76 mmol/L) and a hematocrit level of 30% (0.30). The nurse takes the client's
temperature before hanging the blood transfusion and records 100.6 °F (38.1 °C) orally. Which
action should the nurse take?
1. Begin the transfusion as prescribed.
2. Administer an antihistamine and begin the transfusion.
3. Delay hanging the blood and notify the health care provider (HCP).
4. Administer 2 tablets of acetaminophen and begin the transfusion. - 116. 3
Rationale: If the client has a temperature higher than 100 °F (37.8 °C), the unit of blood should
not be hung until the HCP is notified and has the opportunity to give further prescriptions. The
HCP likely will prescribe that the blood be administered regardless of the temperature, or may
instruct the nurse to administer prescribed acetaminophen and wait until the temperature has
decreased before administration, but the decision is not within the nurse's scope of practice to
make. The nurse needs an HCP's prescription to administer medications to the client.
117. The nurse has received a prescription to transfuse a client with a unit of packed red blood
cells. Before explaining the procedure to the client, the nurse should ask which initial question?
1. "Have you ever had a transfusion before?"
2. "Why do you think that you need the transfusion?"
, 3. "Have you ever gone into shock for any reason in the past?"
4. "Do you know the complications and risks of a transfusion?" - 117. 1
Rationale: Asking the client about personal experience with transfusion therapy provides a good
starting point for client teaching about this procedure. Questioning about previous history of
shock and knowledge of complications and risks of transfusion is not helpful because it may
elicit a fearful response from the client. Although determining whether the client knows the
reason for the transfusion is important, it is not an appropriate statement in terms of eliciting
information from the client regarding an understanding of the need for the transfusion.
118. A client receiving a transfusion of packed red blood cells (PRBCs) begins to vomit. The
client's blood pressure is 90/50 mm Hg from a baseline of 125/78 mm Hg. The client's
temperature is 100.8 °F (38.2 °C) orally from a baseline of 99.2 °F (37.3 °C) orally. The nurse
determines that the client may be experiencing which complication of a blood transfusion?
1. Septicemia
2. Hyperkalemia
3. Circulatory overload
4. Delayed transfusion reaction - 118. 1
Rationale: Septicemia occurs with the transfusion of blood contaminated with microorganisms.
Signs include chills, fever, vomiting, diarrhea, hypotension, and the development of shock.
Hyperkalemia causes weakness, paresthesias, abdominal cramps, diarrhea, and dysrhythmias.
Circulatory overload causes cough, dyspnea, chest pain, wheezing, tachycardia, and
hypertension. A delayed transfusion reaction can occur days to years after a transfusion. Signs
include fever, mild jaundice, and a decreased hematocrit level.
119. The nurse determines that a client is having a transfusion reaction. After the nurse stops
the transfusion, which action should be taken next?
1. Remove the intravenous (IV) line.
2. Run a solution of 5% dextrose in water.
3. Run normal saline at a keep-vein-open rate.
4. Obtain a culture of the tip of the catheter device removed from the client. - 119. 3