90.) The client receiving a unit of PRBCs begins to chill and develops hives.

Which action should be the

nurses first response?

a) notify the laboratory and the physician

b) administer the histamine-1 blocker, Benadryl, IV
c) assess the client for further complications
d) Stop the transfusion and change the tubing at the hub.

91.) The nurse and unlicensed nursing assistant are caring for clients on an oncology floor. Which
nursing task would be delegated to the unlicensed nursing assistant?

a) Assess the urine output on a client who has had a blood transfusion reaction.
b) Take the first 15 minutes of vital signs on a client receiving a unit of PRBCs.
c) Auscultate the lung sounds of a client prior to a transfusion.
d) Assist a client who received ten (10) units of platelets in brushing teeth.

92.) The nurse is caring for clients on a medical floor. After the shift report, which client should be
assessed first?

a) The client who is two-thirds of the way through a blood transfusion and has had no complaints
of dyspnea or hives.
b) The client diagnosed with leukemia who has a hematocrit of 18% and petachiae covering the
body.
c) The client with peptic ulcer diseases who called over the intercom to say that he is vomiting
blood.
d) The client diagnosed with Crohns diseases who is complaining of perineal discomfort.

93.) The client receive two (2) units of packed red blood cells of 250 ml with 63 ml of preservative each
during the shift. There was 240 ml of saline remaining in the 500ml bag when the nurse discarded the
blood tubing. How many milliliters of fluid should be documented on the intake and output record?

a) 886 ml of fluid has infused

b) 887 ml of fluid has infused
c) 888 ml of fluid has infused
d) 889 ml of fluid has infused

94.) The client is diagnosed with severe iron-deficiency anemia. Which statement is the scientific
rationale regarding oral replacement therapy?

a) Iron supplements are well tolerated without side effects.

b) There is no benefit from oral preparations; the best route is IV.
c) Oral iron preparations cause diarrhea if not taken with food.
d) Very little of the iron supplement will be absorbed by the body.
95.) The clients lab values are RBC 5.5 mm (106), WBC 8.9 mm (103). Which intervention should the
nurse implement?

a) Prepare to administer packed red blood cells.

b) Continue to monitor the client
c) Request an order for neupogen, a biologic response modifier.
d) Institute bleeding precautions.

96.) The client diagnosed with anemia is admitted to the emergency department with dyspnea, cool pale
skin, and diaphoresis. Which assessment data warrant immediate intervention?

a) The vital signs are T 98.6 F, P 116, R 28, and BP 88/62.

b) The client is allergic to multiple antibiotic medications.
c) The client has a history of receiving chemotherapy.
d) ABGs are pH 7.35, PCO2 44, HCO3 22, PaO2 92.

97.) The client diagnosed with anemia has an Hgb of 6.1 g/dl. Which complication should the nurse
assess for?

a) Decreased pulmonary functioning.

b) Impaired muscle functioning
c) Congestive heart failure
d) Altered gastric secretions

98.) The nurse writes a diagnosis of activity intolerance for a client diagnosed with anemia. Which
intervention should the nurse implement?

a) Encourage isometric exercises.

b) Assist the client with ADLs
c) Provide a high-protein diet
d) Refer to the physical therapist

99.) The client diagnosed with cancer has been undergoing systemic treatment and has red blood cell
deficiency. Which signs and symptoms should the nurse teach the client to manage?

a) Nausea associated with cancer treatment

b) Shortness of breath and fatigue
c) Controlling mucositis and diarrhea.
d) The emotional aspects of having cancer.

100.) the nurse is assisting the doctor with a bone marrow biopsy. Which intervention postprocedure
has priority?

a) Apply pressure to site for five (5) to ten (10) minutes

b) Medicate for pain with morphine slow IVP
c) Maintain head of bed in a high Fowlers position
d) Apply oxygen via nasal cannula at 5 LPM