NCLEX Secrets - Level of Cognitive Ability
31. The nurse enters a client's room to assess the client, who began receiving a blood transfusion 45 minutes earlier, and notes that the client is flushed and dyspneic. On assessment, the nurse auscultates the presence of crackles in the lung bases. The nurse determines that his client most likely is experiencing which complication of blood transfusion therapy?
a) bacteremia
b) hypovolemia
c) fluid overload
d) transfusion reaction
32. A client has received a transfusion of platelets. The nurse evaluates that the client is benefiting most form this therapy if the client exhibits which of the following?
a) increased hematocrit level
b) increased hemoglobin level
c) decline of elevated temperature to normal
d) decreased oozing of blood from puncture sites and gums
33. The nurse listening to morning reports learns that an assigned client received a unit of granulocytes the previous evening. The nurse makes a note to assess the results of which of the following daily serum laboratory studies to assess the effectiveness of the transfusion?
a) hematocrit level
b) erythrocytes count
c) hemoglobin level
d) white blood cell count
34. A client is brought to the emergency room having experienced blood loss related to an arterial laceration. Fresh frozen plasma (FFP) is ordered and transfused to replace fluid and blood loss. The nurse understands that he rationale for transfusing FFP in this client is to:
a) treat the loss of platelets
b) promote rapid volume expansion
c) that the transfusion must be done slowly
d) that it will increase the hemoglobin and hematocrit levels
35. A nurse obtains an order from a physician to restrain a client by using a jacket restraint and instructs a nursing assistant to apply the restraint to the client. Which observation by the nurse indicates inappropriate application of the restraint by the nursing assistant?
a) a safety knot in the restraint straps
b) restraint straps that are safely secured to the side rails
c) jacket restraint straps that do not tighten when force is applied against them
d) jacket restraint secured so that two fingers can slide easily between the restraint and th client's skin
NCLEX Secrets - Level of Cognitive Ability:
ANSWERS AND RATIONALE
31) C
- with fluid overload, the client has the presence of crackles in addition to dyspnea. An allergic reaction, which is one type of blood transfusion reaction, would produce symptoms such as flushing, dyspnea, itching, and generalized rash. Hypovolemia is not a complication of blood transfusion. With bacteremia, the client would have a fever, which is not part of the clinical picture presented.
32) D
- platelet are necessary for proper blood clotting. The client with insufficient platelets may exhibit frank bleeding or oozing of blood from puncture sites, wounds, and mucous membranes. Increased hemoglobin and hematocrit levels would occur when the client has received a transfusion of red blood cells. An elevated temperature would decline to normal after infusion of granulocytes if those cells were instrumental in fighting infection in the body.
33) D
- the client who has neutropenia may receive a transfusion of granulocytes or white blood cells. These clients often have severe infections and are unresponsive to antibiotic therapy. The nurse notes the results of follow-up white blood cell counts to evaluate the effectiveness of the therapy. The nurse also continues to monitor the client for signs and symptoms of infection. Erythrocyte count and hemoglobin and hematocrit levels are determined after transfusion of packed RBC.
34) B
- fresh frozen plasma is often used for volume expansion as a result of fluid and blood loss. It does not contain platelets, so it is not used to treat any type of low platelet count disorder. It is rich in clotting factors and can be thawed quickly and transfuse quickly. It will not specifically increase the hemoglobin and hematocrit level.
35) B
- the restraint straps are secured to the bed frame and never to the side rail to avoid accidental injury in the event that the side rail is released. A half-bow or safety knot should be used for applying a restraint because it does not tighten when force is applied against it and it allows quick and easy removal of the restraint in case of an emergency. The jacket restraint should be secure, and one to two fingers should slide easily between the restraint and the client's skin.
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NCLEX Secrets - Level of Cognitive Ability Analysis (31-35)
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