Examl 2:l NURl 201/l NUR201l (NEWl 2025/l
2026l Update)l Medical-Surgicall Nursingl Il
Review|l Questionsl &l Answers|l Gradel A|l
100%l Correctl (Verifiedl Solutions)-l Fortis
QUESTION
Al postoperativel patientl receivingl al transfusionl ofl packedl redl bloodl cellsl developsl
chills,l fever,l headache,l andl anxietyl 35l minutesl afterl thel transfusionl isl started.l Afterl
stoppingl thel transfusion,l whatl actionl shouldl thel nursel take?
a.l Sendl al urinel specimenl tol thel laboratory.
b.l Administerl PRNl acetaminophenl (Tylenol).
c.l Drawl bloodl forl al newl typel andl crossmatch.
d.l Givel thel prescribedl PRNl diphenhydramine.
Answer:
B
Thel patient'sl clinicall manifestationsl arel consistentl withl al febrile,l nonhemolyticl
transfusionl reaction.l Thel transfusionl shouldl bel stopped,l andl antipyreticsl administeredl forl
thel feverl asl ordered.l Al urinel specimenl isl neededl ifl anl acutel hemolyticl reactionl isl
suspected.l Diphenhydraminel isl usedl forl allergicl reactions.l Thisl typel ofl reactionl doesl
notl indicatel incorrectl crossmatching.
QUESTION
Al patientl inl thel emergencyl departmentl reportsl backl painl andl difficultyl breathingl 15l
minutesl afterl al transfusionl ofl packedl redl bloodl cellsl isl started.l Whatl shouldl thel nurse'sl
firstl actionl be?
a.l Administerl oxygenl therapyl atl al highl flowrate.
b.l Obtainl al urinel specimenl tol sendl tol thel laboratory.
c.l Notifyl thel healthl carel providerl aboutl thel symptoms.
d.l Disconnectl thel transfusionl andl infusel normall saline.
Answer:
D
Thel patient'sl symptomsl indicatel al possiblel acutel hemolyticl reactionl causedl byl thel
transfusion.l Thel firstl actionl shouldl bel tol disconnectl thel transfusionl andl infusel normall
saline.l Thel otherl actionsl alsol arel neededl butl arel notl thel highestl priority.
,QUESTION
Whichl patientl shouldl thel nursel assignl asl thel roommatel forl al patientl whol hasl aplasticl
anemia?
a.l Al patientl withl chronicl heartl failure
b.l Al patientl whol hasl virall pneumonia
c.l Al patientl whol hasl rightl legl cellulitis
d.l Al patientl withl multiplel abdominall drains
Answer:
A
Patientsl withl aplasticl anemial arel atl riskl forl infectionl becausel ofl thel lowl whitel bloodl
celll productionl associatedl withl thisl typel ofl anemia,l sol thel nursel shouldl avoidl assigningl
al roommatel withl anyl possiblel infectiousl process.
QUESTION
Whichl patientl requiresl thel mostl rapidl assessmentl andl carel byl thel emergencyl
departmentl nurse?
a.l Thel patientl withl hemochromatosisl whol reportsl abdominall pain.
b.l Thel patientl withl neutropenial whol hasl al temperaturel ofl 101.8°l F.
c.l Thel patientl withl thrombocytopenial whol hasl oozingl gumsl afterl al toothl extraction.
d.l Thel patientl withl sicklel celll anemial whol hasl hadl nauseal andl diarrheal forl 24l hours.
Answer:
B
Al neutropenicl patientl withl al feverl isl assumedl tol havel anl infectionl andl isl atl riskl forl
rapidlyl developingl sepsis.l Rapidl assessment,l cultures,l andl initiationl ofl antibioticl therapyl
arel needed.l Thel otherl patientsl alsol requirel rapidl assessmentl andl carel butl notl asl
urgentlyl asl thel neutropenicl patient.
QUESTION
Al patientl withl immunel thrombocytopenicl purpural (ITP)l hasl anl orderl forl al plateletl
transfusion.l Whichl informationl indicatesl thatl thel nursel shouldl consultl withl thel healthl
carel providerl beforel obtainingl andl administeringl platelets?
a.l Plateletl countl isl 42,000/μL.
b.l Bloodl pressurel isl 94/56l mml Hg.
c.l Petechiael arel presentl onl thel chest.
d.l Bloodl isl oozingl froml thel venipuncturel site.
,Answer:
A
Plateletl transfusionsl arel notl usuallyl indicatedl untill thel plateletl countl isl belowl 10,000l tol
20,000/μLl unlessl thel patientl isl activelyl bleeding.l Therefore,l thel nursel shouldl clarifyl thel
orderl withl thel healthl carel providerl beforel givingl thel transfusion.l Thel otherl datal alll
indicatel thatl bleedingl causedl byl ITPl mayl bel occurringl andl thatl thel plateletl transfusionl
isl appropriate
QUESTION
Whichl probleml reportedl byl al patientl withl hemophilial isl mostl importantl forl thel nursel
tol communicatel tol thel healthl carel provider?l a.l Legl bruises
b.l Tarryl stools
c.l Skinl abrasions
d.l Bleedingl gums
Answer:
B
Melenal isl al signl ofl gastrointestinall bleedingl andl requiresl collaborativel actionsl suchl asl
checkingl hemoglobinl andl hematocritl andl administrationl ofl coagulationl factors.l Thel otherl
problemsl indicatel al needl forl patientl teachingl aboutl howl tol avoidl injuryl butl arel notl
indicatorsl ofl possiblel seriousl bloodl loss.
QUESTION
Al patientl withl septicemial developsl prolongedl bleedingl froml venipuncturel sitesl andl
bloodl inl thel stools.l Whichl actionl isl mostl importantl forl thel nursel tol take?
a.l Avoidl otherl venipunctures.
b.l Applyl dressingsl tol thel sites.
c.l Notifyl thel healthl carel provider.
d.l Givel prescribedl proton-pumpl inhibitors
Answer:
C
Thel patient'sl newl onsetl ofl bleedingl andl diagnosisl ofl sepsisl suggestl thatl disseminatedl
intravascularl coagulationl (DIC)l mayl havel developed,l whichl willl requirel collaborativel
actionsl suchl asl diagnosticl testing,l bloodl productl administration,l andl heparinl
administration.l Thel otherl actionsl arel alsol appropriate,l butl thel mostl importantl actionl
shouldl bel tol notifyl thel healthl carel providerl sol thatl DICl treatmentl canl bel initiatedl
rapidly.
, QUESTION
Al patientl withl possiblel disseminatedl intravascularl coagulationl arrivesl inl thel emergencyl
departmentl withl al bloodl pressurel ofl 82/40,l temperaturel ofl 102°l Fl (38.9°l C),l andl
severel backl pain.l Whichl prescribedl actionl willl thel nursel implementl first?l a.l Administerl
morphinel sulfatel 4l mgl IV.
b.l Givel acetaminophenl (Tylenol)l 650l mg.
c.l Infusel normall salinel 500l mLl overl 30l minutes.
d.l Schedulel completel bloodl countl andl coagulationl studies.
Answer:
C
Thel patient'sl bloodl pressurel indicatesl hypovolemial causedl byl bloodl lossl andl shouldl bel
addressedl immediatelyl tol improvel perfusionl tol vitall organs.l Thel otherl actionsl arel alsol
appropriatel andl shouldl bel rapidlyl implemented,l butl improvingl perfusionl isl thel priorityl
forl thisl patient.
QUESTION
Whichl actionl forl al patientl withl neutropenial isl appropriatel forl thel registeredl nursel (RN)l
tol delegatel tol al licensedl practical/vocationall nursel (LPN/VN)?
a.l Assessingl thel patientl forl signsl andl symptomsl ofl infection
b.l Teachingl thel patientl thel purposel ofl neutropenicl precautions
c.l Administeringl subcutaneousl filgrastiml (Neupogen)l injection
d.l Developingl al dischargel teachingl planl forl thel patientl andl family
Answer:
C
Administrationl ofl subcutaneousl medicationsl isl includedl inl LPN/VNl educationl andl scopel
ofl practice.l Patientl teaching,l assessment,l andl developingl thel planl ofl carel requirel RNl
levell educationl andl scopel ofl practice.
QUESTION
Severall patientsl calll thel outpatientl clinicl andl askl tol makel anl appointmentl asl soonl asl
possible.l Whichl patientl shouldl thel nursel schedulel tol bel seenl first?
a.l Al 44-yr-oldl withl sicklel celll anemial whol saysl hisl eyesl alwaysl lookl yellow
b.l Al 23-yr-oldl withl nol previousl healthl problemsl whol hasl al nontenderl axillaryl lump
c.l Al 50-yr-oldl withl early-stagel chronicl lymphocyticl leukemial whol reportsl chronic
fatigue
d.l Al 19-yr-oldl withl hemophilial whol wantsl tol learnl tol self-administerl factorl VII
replacement
2026l Update)l Medical-Surgicall Nursingl Il
Review|l Questionsl &l Answers|l Gradel A|l
100%l Correctl (Verifiedl Solutions)-l Fortis
QUESTION
Al postoperativel patientl receivingl al transfusionl ofl packedl redl bloodl cellsl developsl
chills,l fever,l headache,l andl anxietyl 35l minutesl afterl thel transfusionl isl started.l Afterl
stoppingl thel transfusion,l whatl actionl shouldl thel nursel take?
a.l Sendl al urinel specimenl tol thel laboratory.
b.l Administerl PRNl acetaminophenl (Tylenol).
c.l Drawl bloodl forl al newl typel andl crossmatch.
d.l Givel thel prescribedl PRNl diphenhydramine.
Answer:
B
Thel patient'sl clinicall manifestationsl arel consistentl withl al febrile,l nonhemolyticl
transfusionl reaction.l Thel transfusionl shouldl bel stopped,l andl antipyreticsl administeredl forl
thel feverl asl ordered.l Al urinel specimenl isl neededl ifl anl acutel hemolyticl reactionl isl
suspected.l Diphenhydraminel isl usedl forl allergicl reactions.l Thisl typel ofl reactionl doesl
notl indicatel incorrectl crossmatching.
QUESTION
Al patientl inl thel emergencyl departmentl reportsl backl painl andl difficultyl breathingl 15l
minutesl afterl al transfusionl ofl packedl redl bloodl cellsl isl started.l Whatl shouldl thel nurse'sl
firstl actionl be?
a.l Administerl oxygenl therapyl atl al highl flowrate.
b.l Obtainl al urinel specimenl tol sendl tol thel laboratory.
c.l Notifyl thel healthl carel providerl aboutl thel symptoms.
d.l Disconnectl thel transfusionl andl infusel normall saline.
Answer:
D
Thel patient'sl symptomsl indicatel al possiblel acutel hemolyticl reactionl causedl byl thel
transfusion.l Thel firstl actionl shouldl bel tol disconnectl thel transfusionl andl infusel normall
saline.l Thel otherl actionsl alsol arel neededl butl arel notl thel highestl priority.
,QUESTION
Whichl patientl shouldl thel nursel assignl asl thel roommatel forl al patientl whol hasl aplasticl
anemia?
a.l Al patientl withl chronicl heartl failure
b.l Al patientl whol hasl virall pneumonia
c.l Al patientl whol hasl rightl legl cellulitis
d.l Al patientl withl multiplel abdominall drains
Answer:
A
Patientsl withl aplasticl anemial arel atl riskl forl infectionl becausel ofl thel lowl whitel bloodl
celll productionl associatedl withl thisl typel ofl anemia,l sol thel nursel shouldl avoidl assigningl
al roommatel withl anyl possiblel infectiousl process.
QUESTION
Whichl patientl requiresl thel mostl rapidl assessmentl andl carel byl thel emergencyl
departmentl nurse?
a.l Thel patientl withl hemochromatosisl whol reportsl abdominall pain.
b.l Thel patientl withl neutropenial whol hasl al temperaturel ofl 101.8°l F.
c.l Thel patientl withl thrombocytopenial whol hasl oozingl gumsl afterl al toothl extraction.
d.l Thel patientl withl sicklel celll anemial whol hasl hadl nauseal andl diarrheal forl 24l hours.
Answer:
B
Al neutropenicl patientl withl al feverl isl assumedl tol havel anl infectionl andl isl atl riskl forl
rapidlyl developingl sepsis.l Rapidl assessment,l cultures,l andl initiationl ofl antibioticl therapyl
arel needed.l Thel otherl patientsl alsol requirel rapidl assessmentl andl carel butl notl asl
urgentlyl asl thel neutropenicl patient.
QUESTION
Al patientl withl immunel thrombocytopenicl purpural (ITP)l hasl anl orderl forl al plateletl
transfusion.l Whichl informationl indicatesl thatl thel nursel shouldl consultl withl thel healthl
carel providerl beforel obtainingl andl administeringl platelets?
a.l Plateletl countl isl 42,000/μL.
b.l Bloodl pressurel isl 94/56l mml Hg.
c.l Petechiael arel presentl onl thel chest.
d.l Bloodl isl oozingl froml thel venipuncturel site.
,Answer:
A
Plateletl transfusionsl arel notl usuallyl indicatedl untill thel plateletl countl isl belowl 10,000l tol
20,000/μLl unlessl thel patientl isl activelyl bleeding.l Therefore,l thel nursel shouldl clarifyl thel
orderl withl thel healthl carel providerl beforel givingl thel transfusion.l Thel otherl datal alll
indicatel thatl bleedingl causedl byl ITPl mayl bel occurringl andl thatl thel plateletl transfusionl
isl appropriate
QUESTION
Whichl probleml reportedl byl al patientl withl hemophilial isl mostl importantl forl thel nursel
tol communicatel tol thel healthl carel provider?l a.l Legl bruises
b.l Tarryl stools
c.l Skinl abrasions
d.l Bleedingl gums
Answer:
B
Melenal isl al signl ofl gastrointestinall bleedingl andl requiresl collaborativel actionsl suchl asl
checkingl hemoglobinl andl hematocritl andl administrationl ofl coagulationl factors.l Thel otherl
problemsl indicatel al needl forl patientl teachingl aboutl howl tol avoidl injuryl butl arel notl
indicatorsl ofl possiblel seriousl bloodl loss.
QUESTION
Al patientl withl septicemial developsl prolongedl bleedingl froml venipuncturel sitesl andl
bloodl inl thel stools.l Whichl actionl isl mostl importantl forl thel nursel tol take?
a.l Avoidl otherl venipunctures.
b.l Applyl dressingsl tol thel sites.
c.l Notifyl thel healthl carel provider.
d.l Givel prescribedl proton-pumpl inhibitors
Answer:
C
Thel patient'sl newl onsetl ofl bleedingl andl diagnosisl ofl sepsisl suggestl thatl disseminatedl
intravascularl coagulationl (DIC)l mayl havel developed,l whichl willl requirel collaborativel
actionsl suchl asl diagnosticl testing,l bloodl productl administration,l andl heparinl
administration.l Thel otherl actionsl arel alsol appropriate,l butl thel mostl importantl actionl
shouldl bel tol notifyl thel healthl carel providerl sol thatl DICl treatmentl canl bel initiatedl
rapidly.
, QUESTION
Al patientl withl possiblel disseminatedl intravascularl coagulationl arrivesl inl thel emergencyl
departmentl withl al bloodl pressurel ofl 82/40,l temperaturel ofl 102°l Fl (38.9°l C),l andl
severel backl pain.l Whichl prescribedl actionl willl thel nursel implementl first?l a.l Administerl
morphinel sulfatel 4l mgl IV.
b.l Givel acetaminophenl (Tylenol)l 650l mg.
c.l Infusel normall salinel 500l mLl overl 30l minutes.
d.l Schedulel completel bloodl countl andl coagulationl studies.
Answer:
C
Thel patient'sl bloodl pressurel indicatesl hypovolemial causedl byl bloodl lossl andl shouldl bel
addressedl immediatelyl tol improvel perfusionl tol vitall organs.l Thel otherl actionsl arel alsol
appropriatel andl shouldl bel rapidlyl implemented,l butl improvingl perfusionl isl thel priorityl
forl thisl patient.
QUESTION
Whichl actionl forl al patientl withl neutropenial isl appropriatel forl thel registeredl nursel (RN)l
tol delegatel tol al licensedl practical/vocationall nursel (LPN/VN)?
a.l Assessingl thel patientl forl signsl andl symptomsl ofl infection
b.l Teachingl thel patientl thel purposel ofl neutropenicl precautions
c.l Administeringl subcutaneousl filgrastiml (Neupogen)l injection
d.l Developingl al dischargel teachingl planl forl thel patientl andl family
Answer:
C
Administrationl ofl subcutaneousl medicationsl isl includedl inl LPN/VNl educationl andl scopel
ofl practice.l Patientl teaching,l assessment,l andl developingl thel planl ofl carel requirel RNl
levell educationl andl scopel ofl practice.
QUESTION
Severall patientsl calll thel outpatientl clinicl andl askl tol makel anl appointmentl asl soonl asl
possible.l Whichl patientl shouldl thel nursel schedulel tol bel seenl first?
a.l Al 44-yr-oldl withl sicklel celll anemial whol saysl hisl eyesl alwaysl lookl yellow
b.l Al 23-yr-oldl withl nol previousl healthl problemsl whol hasl al nontenderl axillaryl lump
c.l Al 50-yr-oldl withl early-stagel chronicl lymphocyticl leukemial whol reportsl chronic
fatigue
d.l Al 19-yr-oldl withl hemophilial whol wantsl tol learnl tol self-administerl factorl VII
replacement
