PCC 2 Exam 1 Study Guide Questions With Complete
Answers 100% Solved
A nurse is preparing to administer platelets to a client who has thrombocytopenia.
Which of the following actions should the nurse take?
A. Use a transfusion set that has a short tubing and small filter.
B. Verify the client's blood type with a second nurse.
C. Allow platelets to sit at room temperature for 1 hour prior to infusion.
D. Infuse the platelets over a period of 2 hours. - ANSWER Correct Answer:
A. Use a transfusion set that has a short tubing and a small filter.
Rationale:
The nurse should administer platelets with a special transfusion set that has a smaller
filter and shorter tubing. If a standard blood administration set is used, the filter can
trap the platelets and the longer tubing increases platelet adherence to the lumen.
A nurse is providing teaching to a client who is scheduled to receive one unit of packed
RBCs. Which of the following information should the nurse include in the teaching?
A."It will take approximately 6 hours for this unit of blood to infuse."
B. "You can expect to experience some back discomfort during the infusion."
C. "You will need to lie on your left side while the blood is infusing."
D. "I will remain with you for the first 15 minutes of the transfusion process." - ANSWER
Correct Answer:
D. "I will remain with you for the first 15 minutes of the transfusion process."
Rationale:
The nurse should inform the client that he will remain with the client for the first 15 min
of the transfusion. It is during the first 50 mL of the transfusion that a severe reaction is
most likely to occur.
A nurse is preparing to administer 2 units of packed RBCs to an older adult client. Which
of the following actions should the nurse take?
A. Monitor vital signs every hour during the transfusion.
B. Infuse each unit of blood slowly over 6 hours to avoid flush overload.
, C. Use the same transfusion set to infuse both units of packed RBC's.
D. Wait 2 hours between infusing the two units of packed RBC's. - ANSWER Correct
Answer:
D. Wait 2 hours between infusing the two units of packed RBC's.
Rationale:
If possible, the nurse should wait 2 hr to elapse after the administration of the first unit
of packed RBCs before beginning to infuse the second unit. This will decrease the
client's risk of fluid overload.
Signs and symptoms: Potassium level of 5.5 and flaccid paralysis - ANSWER Correct
Answer:
Respiratory Acidosis or Metabolic Acidosis (pg. 181)
Signs and symptoms: Thready, increased pulse rate; decreased blood pressure and
postural hypotension; flat neck & hand veins; diminished peripheral pulses; increased
temperature - ANSWER Correct Answer:
Dehydration or fluid volume deficit (pg. 229)
Signs and symptoms: Behavioral changes such as lethargy and confusion - ANSWER
Correct Answer:
Respiratory Acidosis or Metabolic Acidosis (pg. 181)
The following IV fluids are considered to be a hypertonic solution:
A. 5% Dextrose Lactate Ringers
B. Lactate Ringers
C. Dextran
D. 5% Dextrose and water - ANSWER Correct Answer:
A &C 5% Dextrose Lactate Ringers and Dextran
The intracellular compartments swells with this type of IV fluid: - ANSWER Correct
Answer:
Hypotonic solution
S/S:
Elevated Hgb and Hct; Specific gravity of 1.301; Elevated sodium, BUN, and serum
osmolarity - ANSWER Correct Answer:
Dehydration or fluid volume deficit (pg. 229)
Answers 100% Solved
A nurse is preparing to administer platelets to a client who has thrombocytopenia.
Which of the following actions should the nurse take?
A. Use a transfusion set that has a short tubing and small filter.
B. Verify the client's blood type with a second nurse.
C. Allow platelets to sit at room temperature for 1 hour prior to infusion.
D. Infuse the platelets over a period of 2 hours. - ANSWER Correct Answer:
A. Use a transfusion set that has a short tubing and a small filter.
Rationale:
The nurse should administer platelets with a special transfusion set that has a smaller
filter and shorter tubing. If a standard blood administration set is used, the filter can
trap the platelets and the longer tubing increases platelet adherence to the lumen.
A nurse is providing teaching to a client who is scheduled to receive one unit of packed
RBCs. Which of the following information should the nurse include in the teaching?
A."It will take approximately 6 hours for this unit of blood to infuse."
B. "You can expect to experience some back discomfort during the infusion."
C. "You will need to lie on your left side while the blood is infusing."
D. "I will remain with you for the first 15 minutes of the transfusion process." - ANSWER
Correct Answer:
D. "I will remain with you for the first 15 minutes of the transfusion process."
Rationale:
The nurse should inform the client that he will remain with the client for the first 15 min
of the transfusion. It is during the first 50 mL of the transfusion that a severe reaction is
most likely to occur.
A nurse is preparing to administer 2 units of packed RBCs to an older adult client. Which
of the following actions should the nurse take?
A. Monitor vital signs every hour during the transfusion.
B. Infuse each unit of blood slowly over 6 hours to avoid flush overload.
, C. Use the same transfusion set to infuse both units of packed RBC's.
D. Wait 2 hours between infusing the two units of packed RBC's. - ANSWER Correct
Answer:
D. Wait 2 hours between infusing the two units of packed RBC's.
Rationale:
If possible, the nurse should wait 2 hr to elapse after the administration of the first unit
of packed RBCs before beginning to infuse the second unit. This will decrease the
client's risk of fluid overload.
Signs and symptoms: Potassium level of 5.5 and flaccid paralysis - ANSWER Correct
Answer:
Respiratory Acidosis or Metabolic Acidosis (pg. 181)
Signs and symptoms: Thready, increased pulse rate; decreased blood pressure and
postural hypotension; flat neck & hand veins; diminished peripheral pulses; increased
temperature - ANSWER Correct Answer:
Dehydration or fluid volume deficit (pg. 229)
Signs and symptoms: Behavioral changes such as lethargy and confusion - ANSWER
Correct Answer:
Respiratory Acidosis or Metabolic Acidosis (pg. 181)
The following IV fluids are considered to be a hypertonic solution:
A. 5% Dextrose Lactate Ringers
B. Lactate Ringers
C. Dextran
D. 5% Dextrose and water - ANSWER Correct Answer:
A &C 5% Dextrose Lactate Ringers and Dextran
The intracellular compartments swells with this type of IV fluid: - ANSWER Correct
Answer:
Hypotonic solution
S/S:
Elevated Hgb and Hct; Specific gravity of 1.301; Elevated sodium, BUN, and serum
osmolarity - ANSWER Correct Answer:
Dehydration or fluid volume deficit (pg. 229)
