Priority Decision: The nurse is preparing to administer a blood transfusion. Number
the actions in order of priority (1 is first priority action; 10 is last priority action).
a. Verify the order for the transfusion.
b. Ensure that the patient has a patent 18-gauge IV.
c. Prime the transfusion tubing and filter with normal saline.
d. Verify that the physician has discussed risks, benefits, and alternatives with the
patient.
e. Obtain the blood product from the blood bank.
f. Ask another licensed person (nurse or MD) to assist in verifying the product
identification and the patient identification.
g. Document outcomes in the patient record. Document vital signs, names of
personnel, and starting and ending times.
h. Adjust the infusion rate and continue to monitor the patient every 30 minutes for up
to an hour after the product is infused.
i. Infuse the first 50mL over 15 minutes, staying with the patient.
j. Obtain the patient's vital signs before starting the transfusion.
Give this one a try later!
, a. 1
b. 3
c. 4
d. 2
e. 5
f. 6
g. 10
h. 9
i. 8
j. 7.
A patient at the clinic says, "I have always taken a walk after dinner, but lately my leg
cramps and hurts after just a few minutes of starting. The pain goes away after I stop
walking, though." The nurse should
a. check for the presence of tortuous veins bilaterally on the legs.
b. ask about any skin color changes that occur in response to cold.
c. assess for unilateral swelling, redness, and tenderness of either leg.
d. assess for the presence of the dorsalis pedis and posterior tibial pulses.
Give this one a try later!
ANS: D
The nurse should assess for other clinical manifestations of peripheral
arterial disease in a patient who describes intermittent claudication.
Changes in skin color that occur in response to cold are consistent with
Raynaud's phenomenon. Tortuous veins on the legs suggest venous
insufficiency. Unilateral leg swelling, redness, and tenderness indicate
venous thromboembolism (VTE).
Which type of transfusion reaction occurs with leukocyte or plasma protein
incompatibility and may be avoided with leukocyte reduction filters?
a. Febrile reaction
b. Allergic reaction
, c. Acute hemolytic reaction
d. Massive blood transfusion reaction
Give this one a try later!
ANS: A. Febrile reaction
Febrile nonhemolytic reaction is the most common transfusion reaction.
Allergic reactions occur with sensitivity to foreign plasma proteins and can
be treated prophylactically with antihistamines. Acute hemolytic reactions
are related to the infusion of ABO-incompatible blood or components with
10 mL or more of RBCs. Massive blood transfusion reactions occur when
patients receive more RBCs or blood than the total blood volume.
The nurse is caring for a patient with type A hemophilia being admitted to the hospital
with severe pain and swelling in the right knee. The nurse should
a. Apply heat to the knee.
b. Immobilize the knee joint.
c. Assist the patient with light weight bearing.
d. Perform passive range of motion to the knee.
Give this one a try later!
ANS: B. Immobilize the knee joint.
The initial action should be total rest of the knee to minimize bleeding. Ice
packs are used to decrease bleeding. Range of motion (ROM) and weight-
bearing exercise are contraindicated initially, but after the bleeding stops,
ROM and physical therapy are started.
Which actions could the nurse delegate to unlicensed assistive personnel (UAP) who
are providing care for a patient who is at risk for venous thromboembolism?
a. Monitor for any bleeding after anticoagulation therapy is started.
the actions in order of priority (1 is first priority action; 10 is last priority action).
a. Verify the order for the transfusion.
b. Ensure that the patient has a patent 18-gauge IV.
c. Prime the transfusion tubing and filter with normal saline.
d. Verify that the physician has discussed risks, benefits, and alternatives with the
patient.
e. Obtain the blood product from the blood bank.
f. Ask another licensed person (nurse or MD) to assist in verifying the product
identification and the patient identification.
g. Document outcomes in the patient record. Document vital signs, names of
personnel, and starting and ending times.
h. Adjust the infusion rate and continue to monitor the patient every 30 minutes for up
to an hour after the product is infused.
i. Infuse the first 50mL over 15 minutes, staying with the patient.
j. Obtain the patient's vital signs before starting the transfusion.
Give this one a try later!
, a. 1
b. 3
c. 4
d. 2
e. 5
f. 6
g. 10
h. 9
i. 8
j. 7.
A patient at the clinic says, "I have always taken a walk after dinner, but lately my leg
cramps and hurts after just a few minutes of starting. The pain goes away after I stop
walking, though." The nurse should
a. check for the presence of tortuous veins bilaterally on the legs.
b. ask about any skin color changes that occur in response to cold.
c. assess for unilateral swelling, redness, and tenderness of either leg.
d. assess for the presence of the dorsalis pedis and posterior tibial pulses.
Give this one a try later!
ANS: D
The nurse should assess for other clinical manifestations of peripheral
arterial disease in a patient who describes intermittent claudication.
Changes in skin color that occur in response to cold are consistent with
Raynaud's phenomenon. Tortuous veins on the legs suggest venous
insufficiency. Unilateral leg swelling, redness, and tenderness indicate
venous thromboembolism (VTE).
Which type of transfusion reaction occurs with leukocyte or plasma protein
incompatibility and may be avoided with leukocyte reduction filters?
a. Febrile reaction
b. Allergic reaction
, c. Acute hemolytic reaction
d. Massive blood transfusion reaction
Give this one a try later!
ANS: A. Febrile reaction
Febrile nonhemolytic reaction is the most common transfusion reaction.
Allergic reactions occur with sensitivity to foreign plasma proteins and can
be treated prophylactically with antihistamines. Acute hemolytic reactions
are related to the infusion of ABO-incompatible blood or components with
10 mL or more of RBCs. Massive blood transfusion reactions occur when
patients receive more RBCs or blood than the total blood volume.
The nurse is caring for a patient with type A hemophilia being admitted to the hospital
with severe pain and swelling in the right knee. The nurse should
a. Apply heat to the knee.
b. Immobilize the knee joint.
c. Assist the patient with light weight bearing.
d. Perform passive range of motion to the knee.
Give this one a try later!
ANS: B. Immobilize the knee joint.
The initial action should be total rest of the knee to minimize bleeding. Ice
packs are used to decrease bleeding. Range of motion (ROM) and weight-
bearing exercise are contraindicated initially, but after the bleeding stops,
ROM and physical therapy are started.
Which actions could the nurse delegate to unlicensed assistive personnel (UAP) who
are providing care for a patient who is at risk for venous thromboembolism?
a. Monitor for any bleeding after anticoagulation therapy is started.
