SAUNDERS COMPREHENSIVE
REVIEW FOR THE NCLEX CH 69
COMPLEX CARE QUESTIONS & A+
GRADED SOLUTIONS
856. A client had a 100 mL bag of 5% dextrose in 0.9% sodium chloride hung at 1500. The nurse
making rounds at 1545 finds that the client is complaining of a pounding headache and is
dyspneic, experiencing chills, and apprehensive, with an increased pulse rate. The intravenous
bag (IV) has 400 mL remaining. The nurse should take which action FIRST?
1. Slow the IV infusion
2. Sit the client up in bed
3. Remove the IV catheter
4. Call the primary health care provider (PHCP) - correct answer ✔✔Answer: 1
Rationale: the client's symptoms are compatible with circulatory overload. This may be verified
by noting that 600mL has been infused in the course of 45 minutes. The first action of the nurse
is to slow the infusion. Other actions may be followed in rapid sequence. The nurse may elevate
the head of the bed to aid in the client's breathing if necessary. The nurse also notifies the PCHP.
the IV catheter is not removed; it may be needed for the administration of medications to
resolve the complication.
857. Packed red blood cells have been prescribed for a female client with anemia who has a
hemoglobin level of 7.6 g/dL (76 mol/L) and a hematocrit level of 30% (0.30). The nurse takes
the client's temperature before the blood transfusion and records 100.6 degrees Fahrenheit
(38.1 degrees Celsius) orally. Which action should the nurse take?
1. Begin the transfusion as prescribed
2. Administer an antihistamine and begin the transfusion
3. Administer 2 tablets of acetaminophen
, 4. Delay hanging the blood and notify the primary health care provider (PHCP) - correct answer
✔✔Answer: 4
Rationale: If the client has a temperature higher than 100 degrees F, the unit of blood should
not be hung until the PHCP is notified and has the opportunity to give further instructions. The
PHCP will likely 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 a PHCPs prescription to administer medication to the client.
858. The nurse is caring for a client experiencing acute lower gastrointestinal bleeding. In
developing the plan of care, which priority problem should the nurse assign to this client?
1. deficient fluid volume related to acute blood loss
2. risk for aspiration related to acute bleeding in the GI tract
3. risk for infection related to acute disease process and medications
4. Imbalanced nutrition, less than body requirements, related to lack of nutrients and increased
metabolism - correct answer ✔✔Answer 1
Rationale: the priority problem for the client with a cute gastrointestinal bleeding among these
options is deficient fluid volume related to acute blood loss. This state can result in decreased
cardiac output and hypovolemic shock. Although nutrition is a problem, fluid volume deficit is
more of a priority. The client is at risk for aspiration and infection, but these are not actual
problems at this point in time.
859. The nurse is assessing the functioning of a chest tube drainage system in a client with a
chest injury who has just returned from the recovery room following a thoracotomy with wedge
resection. SELECT ALL THAT APPLY
1. Excessive Bubbling in the water seal chamber
2. Vigorous bubbling in the suction control chamber
3. Drainage system maintained below the client's chest
REVIEW FOR THE NCLEX CH 69
COMPLEX CARE QUESTIONS & A+
GRADED SOLUTIONS
856. A client had a 100 mL bag of 5% dextrose in 0.9% sodium chloride hung at 1500. The nurse
making rounds at 1545 finds that the client is complaining of a pounding headache and is
dyspneic, experiencing chills, and apprehensive, with an increased pulse rate. The intravenous
bag (IV) has 400 mL remaining. The nurse should take which action FIRST?
1. Slow the IV infusion
2. Sit the client up in bed
3. Remove the IV catheter
4. Call the primary health care provider (PHCP) - correct answer ✔✔Answer: 1
Rationale: the client's symptoms are compatible with circulatory overload. This may be verified
by noting that 600mL has been infused in the course of 45 minutes. The first action of the nurse
is to slow the infusion. Other actions may be followed in rapid sequence. The nurse may elevate
the head of the bed to aid in the client's breathing if necessary. The nurse also notifies the PCHP.
the IV catheter is not removed; it may be needed for the administration of medications to
resolve the complication.
857. Packed red blood cells have been prescribed for a female client with anemia who has a
hemoglobin level of 7.6 g/dL (76 mol/L) and a hematocrit level of 30% (0.30). The nurse takes
the client's temperature before the blood transfusion and records 100.6 degrees Fahrenheit
(38.1 degrees Celsius) orally. Which action should the nurse take?
1. Begin the transfusion as prescribed
2. Administer an antihistamine and begin the transfusion
3. Administer 2 tablets of acetaminophen
, 4. Delay hanging the blood and notify the primary health care provider (PHCP) - correct answer
✔✔Answer: 4
Rationale: If the client has a temperature higher than 100 degrees F, the unit of blood should
not be hung until the PHCP is notified and has the opportunity to give further instructions. The
PHCP will likely 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 a PHCPs prescription to administer medication to the client.
858. The nurse is caring for a client experiencing acute lower gastrointestinal bleeding. In
developing the plan of care, which priority problem should the nurse assign to this client?
1. deficient fluid volume related to acute blood loss
2. risk for aspiration related to acute bleeding in the GI tract
3. risk for infection related to acute disease process and medications
4. Imbalanced nutrition, less than body requirements, related to lack of nutrients and increased
metabolism - correct answer ✔✔Answer 1
Rationale: the priority problem for the client with a cute gastrointestinal bleeding among these
options is deficient fluid volume related to acute blood loss. This state can result in decreased
cardiac output and hypovolemic shock. Although nutrition is a problem, fluid volume deficit is
more of a priority. The client is at risk for aspiration and infection, but these are not actual
problems at this point in time.
859. The nurse is assessing the functioning of a chest tube drainage system in a client with a
chest injury who has just returned from the recovery room following a thoracotomy with wedge
resection. SELECT ALL THAT APPLY
1. Excessive Bubbling in the water seal chamber
2. Vigorous bubbling in the suction control chamber
3. Drainage system maintained below the client's chest
