NCLEX-RN Exam 1 Set three UPDATED Actual Exam Questions and CORRECT Answers
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Course
NCLEX-RN
Institution
NCLEX-RN
NCLEX-RN Exam 1 Set three UPDATED
Actual Exam Questions and CORRECT
Answers
Packed red blood cells have been prescribed for a client with low hemoglobin and hematocrit
levels. The nurse takes the client's temperature before hanging the blood transfusion and
records 100.6° F orally. Which ...
NCLEX-RN Exam 1 Set three UPDATED
Actual Exam Questions and CORRECT
Answers
Packed red blood cells have been prescribed for a client with low hemoglobin and hematocrit
levels. The nurse takes the client's temperature before hanging the blood transfusion and
records 100.6° F orally. Which action should the nurse take? - CORRECT ANSWER✔✔-
Delay hanging the blood and notify the health care provider (HCP).
The nurse has received a prescription to transfuse a client with a unit of packed red blood
cells. Before explaining the procedure to the client, the nurse should ask which initial
question? - CORRECT ANSWER✔✔- "Have you ever had a transfusion before?"
A client receiving a transfusion of packed red blood cells (PRBCs) begins to vomit. The
client's blood pressure is 90/50 mm Hg from a baseline of 125/78 mm Hg. The client's
temperature is 100.8° F orally from a baseline of 99.2° F orally. The nurse determines that the
client may be experiencing which complication of a blood transfusion? - CORRECT
ANSWER✔✔- Septicemia
Rationale:
Septicemia occurs with the transfusion of blood contaminated with microorganisms. Signs
include chills, fever, vomiting, diarrhea, hypotension, and the development of shock.
What does hyperkalemia cause? - CORRECT ANSWER✔✔- Hyperkalemia causes
weakness, paresthesias, abdominal cramps, diarrhea, and dysrhythmias.
What does circulatory overload cause? - CORRECT ANSWER✔✔- Circulatory overload
causes cough, dyspnea, chest pain, wheezing, tachycardia, and hypertension.
A client has received a transfusion of platelets. The nurse evaluates that the client is
benefiting most from this therapy if the client exhibits which finding? - CORRECT
ANSWER✔✔- Decreased oozing of blood from puncture sites and gums
,The nurse has obtained a unit of blood from the blood bank and has checked the blood bag
properly with another nurse. Just before beginning the transfusion, the nurse should assess
which priority item? - CORRECT ANSWER✔✔- Vital signs
Rationale:
A change in vital signs during the transfusion from baseline may indicate that a transfusion
reaction is occurring. This is why the nurse assesses vital signs before the procedure and
again after the first 15 minutes.
The nurse has just received a prescription to transfuse a unit of packed red blood cells for an
assigned client. Approximately how long will the nurse need to stay with the client to ensure
that a transfusion reaction is not occurring? - CORRECT ANSWER✔✔- 15 minutes
The nurse, listening to the morning report, learns that an assigned client received a unit of
granulocytes the previous evening. The nurse makes a note to assess the results of which
daily serum laboratory studies to assess the effectiveness of the transfusion? - CORRECT
ANSWER✔✔- White blood cell count
A client is brought to the emergency department having experienced blood loss related to an
arterial laceration. Fresh-frozen plasma is prescribed and transfused to replace fluid and
blood loss. The nurse understands that which is the rationale for transfusing fresh-frozen
plasma to this client? - CORRECT ANSWER✔✔- To promote rapid volume expansion
The nurse who is about to begin a blood transfusion knows that blood cells start to deteriorate
after a certain period of time. Which item is important to check regarding the age of blood
cells before the transfusion is begun? - CORRECT ANSWER✔✔- Expiration date
A client with severe blood loss resulting from multiple trauma requires rapid transfusion of
several units of blood. The nurse asks another health team member to obtain which device for
use during the transfusion procedure to help reduce the risk of cardiac dysrhythmias? -
CORRECT ANSWER✔✔- Blood warming device
A client has a prescription to receive a unit of packed red blood cells. The nurse should obtain
which intravenous (IV) solution from the IV storage area to hang with the blood product at
the client's bedside? - CORRECT ANSWER✔✔- 0.9% sodium chloride
, The nurse is performing an assessment on a client who has been receiving parenteral nutrition
at 125 mL/hour. On assessment, the nurse notes the presence of bilateral crackles in the lungs
and 2+ pedal edema. The nurse also notes that the client has gained 3 pounds in 5 days.
Which nursing action would be most appropriate for this client? - CORRECT ANSWER✔✔-
Notify HCP
The nurse is caring for a client who is receiving total parenteral nutrition (TPN) via a central
line. Which nursing intervention would specifically provide assessment data related to the
most common complication associated with TPN? - CORRECT ANSWER✔✔- Monitoring
temperature because the most common complication is infection.
The nurse is developing a plan of care for a client who is receiving total parenteral nutrition
(TPN). The nurse identifies assessments to be made to help identify complications related to
the infusion of the TPN solution. The care plan should include monitoring of which
assessment item(s)? - CORRECT ANSWER✔✔- Blood glucose levels
One unit of packed red blood cells has been prescribed for a client with severe anemia. The
client has received multiple transfusions in the past, and it is documented that the client has
experienced urticaria-type reactions from the transfusions. The nurse anticipates that which
medication will be prescribed before administration of the red blood cells to prevent this type
of reaction? - CORRECT ANSWER✔✔- Diphenhydramine (Benadryl)
Fat emulsion is prescribed for the client receiving parenteral nutrition. The nurse is preparing
to administer the fat emulsion and notes the presence of fat globules in the solution. What
should the nurse do? - CORRECT ANSWER✔✔- Return the solution to the pharmacy.
A client receiving total parenteral nutrition experiences sudden development of chest pain,
dyspnea, tachycardia, cyanosis, and a decreased level of consciousness. What should the
nurse suspect as a complication of the total parenteral nutrition? - CORRECT ANSWER✔✔-
Air embolism
A client receiving parenteral nutrition through a central intravenous (IV) line is scheduled to
receive an antibiotic by the IV route. Which action by the nurse is appropriate before hanging
the antibiotic solution? - CORRECT ANSWER✔✔- Ensure a separate IV access for the
antibiotic.
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