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WorksheetsQuestions 4-7
Total questions: 64
Worksheet time: 33mins
A nurse is caring for a client with thrombocytopenia. Which interventions are appropriate? Select all that apply.
Apply pressure to bleeding sites for 10 minutes
Assist with ambulation as tolerated
Obtain rectal temperatures every 4 hours
Measure and document urine output
Use electric razor for shaving
The nurse is caring for a client with erythrocytosis. Which interventions reduce the client’s risk for the most serious complication? Select all that apply.
Encourage use of sequential compression devices (SCDs)
Promote hydration
Administer iron supplements
Encourage early ambulation
Apply ice packs to extremities
A nurse is caring for a client experiencing a febrile transfusion reaction. Which clinical manifestations would support this diagnosis? Select all that apply.
Fever
Chills
Flank pain
Hypotension
Headache
Which signs/symptoms are most consistent with an acute hemolytic transfusion reaction? Select all that apply.
Hematuria
Fever and chills
Low back pain
Signs of shock
Urticaria
A nurse suspects a client is experiencing an allergic transfusion reaction. Which cues would the nurse expect? Select all that apply.
Hives
Itching
Flushing
Dyspnea
Anxiety
Signs of fluid overload during a blood transfusion include which of the following?
Shortness of breath, and increased blood pressure
Fever, chills, and back pain
Rash, itching, and hives
Nausea, vomiting, and diarrhea
Which of the following clients is receiving an appropriate type of blood for their blood type? Select all that apply.
Client with B negative receiving O negative blood
Client with B negative receiving B negative blood
Client with B negative receiving B positive blood
Client with B negative receiving O positive blood
The nurse is teaching about evaluating transfusion effectiveness for a client receiving RBCs. Which outcomes indicate success? Select all that apply.
Hemoglobin increases by 1 g/dL per unit transfused
Hematocrit decreases by 3%
Improved oxygenation and energy levels
Increased Prothrombin Time
No transfusion reaction symptoms
Identify the incorrect nursing interventions for a client with erythrocytosis from the following options.
Encouraging frequent ambulation to prevent thrombosis
Applying warm compresses to promote circulation
Restricting fluid intake to reduce blood volume
Monitoring for signs of bleeding and thrombosis
A nurse caring for a client with thrombocytopenia should intervene if which actions are observed? Select all that apply.
Taking an oral temperature
Measuring urine output hourly
Obtaining a rectal temperature
Assisting with ambulation
A client receiving a blood transfusion develops hives, flushing, and anxiety. Which actions should the nurse take? Select all that apply.
Stop the transfusion immediately
Maintain IV access with normal saline
Notify the provider
Reassure the client and monitor vital signs
Restart the transfusion after symptoms resolve
A client with B negative blood type is accidentally sent B positive blood for transfusion. Which actions should the nurse take? Select all that apply.
Stop the verification/administration process immediately
Document the error in the client’s chart without telling the provider
Notify the blood bank and provider immediately
Continue with transfusion to prevent wasting blood
Return the blood to the blood bank
A nurse caring for a client with thrombocytopenia should intervene if which action is observed?
Vigorous teeth brushing
Applying pressure to a bleeding site for 10 minutes
Avoiding aspirin
Asking for assisting to the bathroom
A client with erythrocytosis is at greatest risk for which complication?
Hemorrhage
Thrombosis
Hypotension
Infection
Which intervention is most appropriate for preventing complications in a client with erythrocytosis?
Applying ice packs to extremities
Encouraging early ambulation
Administering iron supplements
Limiting fluid intake
A febrile transfusion reaction is caused by:
Incompatible donor red blood cells
Rapid infusion rate of blood products
Antibodies reacting to donor lymphocyte antigens
Volume overload from excess transfusion
A client with a hemolytic transfusion reaction is likely to present with:
Hives, flushing, itching
Low back pain, hematuria, signs of shock
Elevated BP, crackles, JVD
Fever, chills, headache
Which finding is most consistent with an allergic transfusion reaction?
Fever and chills
Crackles in lungs
Hives and itching
Low back pain
A nurse monitoring for fluid overload during transfusion should be alert for:
Hypotension and tachycardia
Dyspnea and jugular vein distention
Hematuria and flank pain
Hives and itching
A client with A negative blood type can safely receive which blood type(s)?
O positive and A negative
A negative and O negative
O negative and AB negative
A positive and AB negative
A nurse evaluates the effectiveness of a RBC transfusion. Which is not an expected finding?
Hemoglobin increase by 1 g/dL per unit transfused
Decrease tissue perfusion
Increased hematocrit by 3% per unit transfused
Reduced difficulty breathing
When the nurse realizes the blood delivered for transfusion is incompatible with the client’s blood type, the priority action is to:
Notify the provider
Stop the verification/administration process
Document the incident
Return the blood to the blood bank after infusion
A client with severe anemia reports chest pain. Which is the most likely cause?
Bone pain from marrow expansion
Myocardial ischemia from low oxygen delivery
Pallor due to decreased hemoglobin
Dyspnea from mild anemia
A client with pernicious anemia asks about treatment. Which response is correct?
You will need vitamin B12 injections.
We will start iron supplements.
You should increase dairy intake.
A blood transfusion is the standard treatment.
A client with renal failure has anemia. Which medication should the nurse anticipate?
Erythropoietin
Vitamin B12 injection
Platelet transfusion
Intravenous iron
Which finding in a client with aplastic anemia requires immediate intervention?
Eating fresh blueberries
Taking NSAIDs for joint pain
Temperature of 99°F (37.2°C)
Wearing a mask in public
A client with a hemoglobin of 8 g/dL, HR 124, BP to 92/48 mm Hg, and SpO₂ 89% is being reassessed after transfusion of one unit of blood. Which finding is most concerning?
BP to 100/58 mm Hg
HR decreased to 101
SpO₂ 87%
Hematocrit increased by 3%
Which client should the nurse see first?
Client with nausea awaiting ondansetron
A patient with a blood glucose level of 400 mg/dL, who is alert and oriented
Client with BP 86/58 and suspected GI bleed
Client awaiting a cholecystectomy
Post-bariatric surgery, which intervention should the nurse implement first?
Ambulate as tolerated
Give 500 mL of water every 2 hours
Position head of bed flat
Advance to solid foods on post-op day 1
A client asks how to avoid dumping syndrome after bariatric surgery. Which statement shows correct understanding?
I’ll drink fluids with meals.
I’ll avoid sugary foods.
I can eat fatty meals.
I’ll lie flat after eating.
Which medication administration method is best for a client with a feeding tube?
Requesting liquid formulations when possible
Mixing pills directly with tube feeding
Withholding meds for any gastric residual
Placing client supine for comfort
A nurse caring for a client with aplastic anemia should implement which infection control measure?
Negative pressure isolation
Positive pressure protective isolation
Contact precautions only
No special isolation is needed
Findings most concerning in severe anemia:
Pallor
Bone pain
Chest pain
Dyspnea on exertion
Fatigue
Treatments for pernicious anemia:
Vitamin B12 injection
Iron supplements
Blood transfusion
Increase dairy intake
Causes of anemia in renal failure:
Blood loss
Decreased erythropoietin production
Vitamin B12 and Folate excess
Increased red blood cell production
SATA 4 – Aplastic anemia precautions: Select all that apply.
No fresh fruits/vegetables
Continuous pulse oximetry
Meticulous hand hygiene
Notify HCP for temp >100.4°F
Use a firm-bristled toothbrush
SATA 5 – Worsening signs after transfusion: Select all that apply.
Increased in BP from baseline
Drop in BP from baseline
Decrease in heart rate from baseline
Increased heart rate from baseline
SATA 6 – First actions for unstable bleeding ulcer: Select all that apply.
Notify provider
Administer antiemetic
Prepare for fluid resuscitation
Monitor vital signs
Provide high-protein diet
SATA 7 – Post-bariatric surgery priorities: Select all that apply.
Early ambulation
SCDs or heparin for DVT prevention
High-protein liquid diet
160 mL water every 2 hrs
Eat slowly and chew food thoroughly
SATA 8 – Prevent dumping syndrome:
Avoid sugary foods
Drink fluids with meals
Eat smaller meals
Lie down after eating
Consume fluids between meals
SATA 9 – Safe med administration via feeding tube:
Request liquid forms
Mix meds with feeding formula
Flush before/after meds
Hold meds for residual >200 mL and notify provider
Give meds supine
SATA 10 – Which statements show a good understanding of Infection prevention in aplastic anemia:
Don't get an annual flu shot
Don't use public pools or hot tub
Don't participate in contact sports or activities
Don't share personal items
Select all appropriate interventions for a client with severe neutropenia:
Have someone else handle pet waste
Report pain with urination
Use a pumice stone to remove cracks
Use a rectal suppositories if constipated
Wear a mask in public settings
A nurse is caring for a client with severe anemia who has been admitted with high-output heart failure. Which of the following is the most likely initial treatment priority?
Administering a diuretic to reduce fluid volume
Prescribing an ACE inhibitor to improve cardiac function
Initiating a blood transfusion to increase oxygen-carrying capacity.
Administering intravenous fluids to increase blood volume
A client with aplastic anemia is admitted for fever and bleeding gums. What is the diagnosis for this client?
Pancytopenia due to aplastic anemia
Leukocytosis due to infection
Polycythemia vera
Thrombocytosis due to iron deficiency
A client with a small bowel obstruction has been receiving enteral tube feedings. Which action is most appropriate?
Continue feedings at a slower rate
Switch to a clear liquid diet
Prepare for parenteral feedings
Administer protein shakes by mouth
Which client is an appropriate candidate for enteral feedings?
Small bowel obstruction
Severe dysphagia with intact GI tract
Peritonitis
Postoperative ileus
A nurse must stop a client’s TPN infusion unexpectedly. Which solution should be started to prevent hypoglycemia?
Lactated Ringer’s
0.9% Normal saline
D10W solution
5% dextrose in 0.45% saline
A client with GERD asks which drinks to avoid. Which is the best response?
Herbal Tea
Carrot juice
Seltzer Water
Oat milk
Following a percutaneous endoscopic gastrostomy (PEG) tube insertion, a nurse notes several findings. Which finding is the highest priority for the nurse to report immediately to the healthcare provider?
The client reports mild discomfort at the insertion site.
The nurse observes a small amount of serous drainage around the tube
The client's heart rate is elevated, and abdominal rigidity is noted.
The client's blood glucose level is 130 mg/dL.
A nurse is caring for a client with a suspected acute gastrointestinal (GI) bleed, who has just experienced a large episode of hematemesis. What is the immediate priority nursing action?
Assess the client's vital signs, including blood pressure and heart rate.
Insert a nasogastric (NG) tube to lavage the stomach.
Assess the client's last bowel movement for melena.
Prepare the client for an immediate blood transfusion.
A nurse is assessing a client with joint pain. Which of the following assessment findings most strongly suggests the client has rheumatoid arthritis (RA) rather than osteoarthritis (OA)?
The client reports joint pain that worsens with activity.
The nurse notes the client's hands have metacarpophalangeal (MCP) joint deformities
The client reports symptoms such as fever and malaise
The nurse notes the client's hands have Heberden's and Bouchard's nodes.
A nurse is providing discharge teaching to a client with a new ileostomy. Which statement by the client indicates a need for further teaching?
"I will drink at least two to three liters of fluid every day."
"I will avoid foods like corn, popcorn, and nuts."
"I should empty my pouch when it is about one-third to one-half full."
"I will take a vitamin B12 supplement daily to prevent anemia."
A nurse is teaching a client with a new ileostomy about potential complications. The nurse instructs the client to immediately report which symptom to the healthcare provider?
Mild irritation of the skin around the stoma.
High-volume, watery output from the stoma.
A decrease in the size and color of the stoma.
Swollen, puffy skin around the stoma.
A nurse is teaching a client with a colostomy about diet. Which of the following foods would not be recommend?
Applesauce and bananas
Beans and rice
Watermelon and grapes
Chicken and rice
Who may benefit from enteral feedings?
A client with a small bowel obstruction
A client with severe dysphagia
A client with a traumatic brain injury
A client with anorexia nervosa
A client with a complete bowel perforation
A nurse is caring for a client with an external fixation device on an injured leg. The nurse is providing education on the key differences between this device and an internal fixation device. Which statement indicates the client understands the purpose of an external fixator?
"This device will remain in place indefinitely to support the bone."
"The external pins allow the doctor to adjust my bone alignment without another surgery."
"This device is a safer option because it completely eliminates the risk of infection."
"I will be able to bear full weight on my leg immediately after the surgery.
Which of the following findings are most consistent with Peptic Ulcer Disease (PUD)? (Select all that apply)
Gnawing or burning pain in the epigastric region.
Pain that is relieved by eating food.
Heartburn that is worse when lying down or bending over.
Pain that awakens the client at night.
Pain that occurs 30-60 minutes after eating.
SATA 4 – Post-endoscopy findings that are urgent:
Severe abdominal pain
Abdominal rigidity
Sore throat
Absent gag reflex
Fever with chills
SATA 5 – Priority assessment in suspected GI bleed:
Blood pressure
Pulse rate
Quantity of emesis
Abdomen tenderness
Breath sounds
A patient develops signs of anaphylaxis during an IV antibiotic infusion. Which of the following are the nurse’s immediate priority actions? Select all that apply.
Stop the infusion after a respiratory assessment
Place the patient in Trendelenburg position to increase venous return
Administer Epinephrine to lower the blood pressure
Provide oxygen as needed and prepare for a possible intubation
The nurse is teaching a group of nursing students about Methicillin-Resistant Staphylococcus aureus (MRSA). Which of the following statements about MRSA are correct? Select all that apply.
MRSA is resistant to many commonly used antibiotics, including methicillin and penicillin.
Patients with MRSA infections should be placed on contact precautions.
MRSA infections can only be acquired in hospitals and healthcare facilities
MRSA can live on surfaces and equipment, contributing to transmission.
Signs of electrolyte imbalance in ileostomy clients:
Muscle cramps
Weakness
Numbness/tingling
Insomnia
Confusion
The nurse is caring for several patients. Which of the following situations place a patient at risk for compartment syndrome? Select all that apply.
A patient with a tibia fracture placed in a cast
A patient with a crush injury after a car accident
A patient who recently had a cast removed
A patient with reperfusion injury after tourniquet release
A patient with extensive burns causing swelling
