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FUNDAMENTALS OF NURSING (SACI Course Audit)

Post Test

HISTORICAL BACKGROUND NURSING


1. Which of the following is the exact order of the 5 Major Dimensions/Periods in
the History and Development of Nursing?
A.Educative,Intuitive,Apprentice,Dark,Contemporary
B.Intuitive, Apprentice,Dark,Educative,Contemporary
C.Contemporary,Dark,Educative,Apprentice,Intuitive
D.Intuitive,Apprentice,Educative,Dark,Contemporary
2. In a Medical-Surgical Unit, the staff nurses are very particular with the
provision of the RIGHT ENVIRONMENT to their patients. The act of utilizing the
environment of the patient to assist him in his recovery is theorized by
A.Nightingale
B.Neuman
C.King
D.Leininger
Nightingale environmental theory
Neuman Stress Reduction Theory
King Goal attainment theory
Leininger Transcultural theory
3. Which of the following nursing theorists conceptualized the model for
determining whether a patient is on wholly compensatory, partially
compensatory or supportive educative state?
A. Sister Callista Roy
B. Dorothea Orem
C. Dorothy Johnson
D. Jean Watson
Roy adaptation model
Orem self care. Self care deficit and theory of nursing systems
Johnson behavioural model
Watson humanistic caring theory
4. Which of the following is a conservation principle by Myra Levine?
A. Conservation of Structural Integrity
B. Conservation of Relativity
C. Conservation of Water
D. Conservation of Multifactorial Integrity
4 conservation principles by Myra Levine
1. Energy
2. Structural integrity
3. Personal integrity
4. Social integrity

STRESS & COPING STRATEGIES


5. Stress is endemic to every persons daily life. The following are physiologic
responses to stress, EXCEPT:
A. Diaphoresis
B. Bronchodilation
C. Dilation of Pupils
D. Increased Salivation
6. When the General adaptation syndrome is activated, FLIGHT OR FIGHT
response sets in. Sympathetic nervous system releases norephinephrine
while the adrenal medulla secretes epinephrine. Which of the following is
true with regards to that statement?
A. Pupils will constrict
B. Client will be lethargic
C. Lungs will bronchodilate
D. Gastric motility will increase
Rationale: To better understand the concept : The autonomic nervous system
is composed of SYMPATHETIC and PARASYMPATHETIC Nervous system. It is
called AUTONOMIC Because it is Involuntary and stimuli based. You cannot
tell your heart to kindly beat for 60 per minute, Nor, Tell your blood vessels,
Please constrict, because you need to wear skirt today and your varicosities
are bulging. Sympathetic Nervous system is the FIGHT or FLIGHT mechanism.
When people FIGHT or RUN, we tend to stimulate the ANS and dominate over
SNS. Just Imagine a person FIGHTING and RUNNING to get the idea on the
signs of SNS Domination. Imagine a resting and digesting person to get a
picture of PNS Domination. A person RUNNING or FIGHTING Needs to
bronchodilate, because the oxygen need is increased due to higher demand
of the body. Pupils will DILATE to be able to see the enemy clearly. Client will
be fully alert to dodge attacks and leap through obstacles during running.
The client's gastric motility will DECREASE Because you cannot afford to
urinate or defecate during fighting nor running.
7. Which of the following response is NOT expected to a person whose GAS is
activated and the FIGHT or FLIGHT response sets in?
A. The client will not urinate due to relaxation of the detrusor muscle
B. The client will be restless and alert
C. Clients BP will increase there will be vasodilation
D. There will be increase RR due to bronchodilation
Rationale: If vasodilation will occur, The BP will not increase but decrease. It
is true that Blood pressure increases during SNS Stimulation due to the fact
that we need more BLOOD to circulate during the FIGHT or FLIGHT Response
because the oxygen demand has increased, but this is facilitated by
vasoconstriction and not vasodilation. A,B and D are all correct. The liver will
increase glycogenolysis or glycogen store utilization due to a heightened
demand for energy. Pancrease will decrease insulin secretion because almost

every aspect of digestion that is controlled by Parasympathetic nervous


system is inhibited when the SNS dominates.
8. The primary substance responsible for dilating blood vessels during
inflammatory response is:
A. Endorphin
B. Epinephrine
C. Serotonin
D. Bradykinin
9. The first manifestation of inflammation is
A. Redness on the affected area
B. Swelling of the affected area
C. Pain, which causes guarding of the area
D. Increase heat due to transient vasodilation
PRINCIPLES OF PRECAUTIONS AND INFECTION CONTROL
10.Kenneth has developed diarrhea from ROTAVIRUS. What type of precaution
measures are to be instituted?
A. Contact, gloves, gown, goggles
B. Airborne, N95 mask
C. Contact, surgical mask
D. Droplet, surgical mask
11.Mark has been diagnosed to have Whooping cough. What type of precaution
must be instituted?
A. Droplet, surgical mask
B. Contact, gloves, gowns, goggles
C. Airborne, N95
D. Contact, surgical mask
12.The most effective way to break the chain of infection is by:
A. Wearing gloves
B. Hand hygiene
C. Placing clients in isolation
D. Providing private rooms for clients
FUNDAMENTAL HUMAN NEEDS: OXYGENATION
**NOTE: ACTUAL BOARD EXAM QUESTION JUNE2008 & 2009 NLE!
13.The nurse is evaluating a clients lung sounds. Which of the following breath
sounds indicate adequate ventilation when auscultated over the lung fields?
A. Vesicular
B. Bronchial
C. Bronchovesicular
D. Adventitious
Normal:

There are two normal breath sounds. Bronchial and vesicular. Breath sounds
heard over thetracheobronchial tree are called bronchial breathing and
breath sounds heard over the lung tissue are called vesicular breathing. The
only place where tracheobronchial trees are close to chest wall without
surrounding lung tissue are trachea, right sternoclavicular joints and
posterior right interscapular space. These are the sites where bronchial
breathing can be normally heard. In all other places there is lung tissue and
vesicular breathing is heard.
The bronchial breath sounds over the trachea has a higher pitch, louder,
inspiration and expiration are equal and there is a pause between inspiration
and expiration.
The vesicular breathing is heard over the thorax, lower pitched and softer
than bronchial breathing. Expiration is shorter and there is no pause between
inspiration and expiration. The intensity of breath sound is higher in bases in
erect position and dependent lung in decubitus position.
The breath sounds are symmetrical and louder in intensity in bases
compared to apices in erect position. No adventitious sounds are heard.
Breath Sounds by Dr David W.Cugell NW University Chicago
SITUATION: John Mark is 21 year old male client who was rushed following an
automobile accident. He is very anxious, dyspneic and in severe pain. Refer to
question numbers 14-15
14.To ensure that the system is functioning effectively, the nurse should:
A. Observe for intermittent bubbling in the water seal chamber
B. Flush the chest tube with 30 to 60 mL of NSS every 4 hours
C. Maintain the client in a side-lying position always
D. Strip the chest tube in the direction of towards the client
15.JMs chest tube is said to be functioning correctly when which of the following
is observed?
A. Continuous bubbling in the waterseal chamber
B. Fluctuation in the water seal chamber
C. Drainage chamber more than 100ml/hr
D. Absent breath sounds heard in all lung fields
Closed chest drainage.
One or more tubes may be inserted to:
1. Restore intrapleural pressure
2. Allow re-expansion of lungs
3. Prevents air and fluid from returning to the chest
Tube to drain air is located near apex (top); to drain fluid is located near base
(bottom). A chest tube that allows air to escape from the chest will be placed
anterior and superior in the chest because air within the pleural space will
rise to the highest point in the chest. A chest tube to drain fluid or blood will
be placed posterior and inferior because fluid will collect in the most
dependent part of the pleural space.

The insertion site should be covered with airtight dressingtubes are usually
sutured in place. Tape all connections to ensure they do not become loose.
The chest drainage system should always be kept below the level of the
chest.
Tubing:
1. Should be coiled on the bed.
2. No dependent loops.
3. Avoid kinks in tubing.
4. Do NOT milk clots from line.
Pleurovac Three chambers.
1. Drainage chamber (look right to left)
2. Water seal
3. Suction
The water seal chamber acts as a one-way valve (air goes out, none goes
in). Monitor for continuous bubbling in the water seal chamber. Bubbles on
forceful expiration or coughing, not normal otherwise. Intermittent bubbling
in water seal chamber with forced expiration or cough is OK. Continuous
bubbling in the water seal is abnormal and indicates an air leak. IF the nurse
notes that there is CONTINUOUS bubbling in the water seal chamber, check
for leaks in the system. With physicians order, RN places padded clamp
closest to dressing. If leak stops, air leak is at insertion site. If bubbling
continues, leak is between clamp and drainage system.
Water should rise and fall in water seal (undulate) with respirations due to
pressure changes in pleural space.
Undulation: increase with inspiration, decrease tidal wave with expiration.
No fluctuations or tidal undulations in water seal:
1. Tube is kinked
2. Pt laying on tube
3. Fluid in the tube
4. Lung fully expanded (blocking the tube eyelets)
Suction chamber: While suction is applied, it is normal to have gentle
bubbling in the suction chamber. Suctioncan be applied to enhance
pressure differences. Very low wall suction: 5-10 mm Hg. There will be gentle
bubbling (should not be vigorous bubbling) in the suction chamber.
Drainage collection chamber: Do not empty the contents. Monitor chest tube
drainage q 15 minutes for at least 4 hours then at hourly intervals, for the
first 24 hours, depending on the amount of drainage. Record hourly
drainage.Mark level of drainage with marker on drainage collection
chamber. Should NOT be more that 100 ml/hr.Over 100 ml/hris excessive
notify physician. After first 24 hours, assess drainage every 8 hours.
Junctions at tube connectors are taped to avoid dislodgement.

If chest tube becomes dislodged:


> Cover area with sterile (preferably Vaseline or another occlusive type)
gauze.
> Clamps are kept at bedside is system is disrupted or to facilitate device
change.
SITUATION: Respiration is one of the most important vital sign. This is usually the
first vital sign to be assessed more than anything for it easily altered by the
patients consciousness. The nurse should be aware of the different changes and
alteration in respiration. Refer to question numbers 16-18
16.Another name for an abnormal breath sound is:
A. Adventurous breath sound
B. Excursion
C. Adventitious breath sound
D. Dyspea
17.If the nurse will auscultate the base of the base of the lungs, it is expected
that she will hear:
A. Bronchovesicular
B. Tubular
C. Vesicular
D. Crackles
18.The respiratory center is found in the:
A. Substancia nigra
B. Hypothalamus
C. Medulla
D. Lungs
Situation: Richard has a nursing diagnosis of ineffective airway clearance related to
excessive secretions and is at risk for infection because of retained secretions. Part
of Nurse Marios nursing care plan is to loosen and remove excessive secretions in
the airway. Refer to question numbers 19-23
19.Nurse Mario listens to Richards bilateral sounds and finds that congestion is
in the upper lobes of the lungs. The appropriate position to drain the anterior
and posterior apical segments of the lungs when Nurse Mario does percussion
would be:
A. Client lying on his back then flat on his abdomen on Trendelenburg position
B. Client seated upright in bed or on a chair then leaning forward in sitting
position then flat on his back and on his abdomen
C. Client lying flat on his back and then flat on his abdomen
D. Client lying on his right then left side on Trendelenburg position
20.When documenting outcome of Richards treatment, Nurse Mario should
include the following in his recording EXCEPT:
A. Color, amount and consistency of sputum
B. Character of breath sounds and respiratory rate before and after procedure

C. Amount of fluid intake of client before and after the procedure


D. Significant changes in vital signs
21.When assessing Richard for chest percussion or chest vibration and postural
drainage, Nurse Mario would focus on the following EXCEPT:
A. Amount of food and fluid taken during the last meal before treatment
B. Respiratory rate, breath sounds and location of congestion
C. Teaching the clients relatives to perform the procedure
D. Doctors order regarding position restrictions and clients tolerance for
lying flat
22.Nurse Mario prepares Richard for postural drainage and percussion. Which of
the following is a special consideration when doing the procedure?
A. Respiratory rate of 16 to 20 per minute
B. Client can tolerate sitting and lying positions
C. Client has no signs of infection
D. Time of last food and fluid intake of the client
23.The purpose of chest percussion and vibration is to loosen secretions in the
lungs. The difference between the procedures is:
A. Percussion uses only one hand while vibration uses both hands
B. Percussion delivers cushioned blows to the chest with cupped palms
while vibration gently shakes secretion loose on the exhalation cycle
C. In both percussion and vibration the hands are on top of each other
and hand action is in tune with clients breath rhythm
D. Percussion slaps the chest to loosen secretions while vibration
shakes the secretions along with the inhalation of air
FUNDAMENTAL HUMAN NEEDS: NUTRITION
24.Which Vitamin is not given in conjunction with the intake of LEVODOPA in
cases of Parkinsons Disease due to the fact that levodopa increases its level
in the body?
A. Vitamin B1
B. Vitamin B2
C. Vitamin B3
D. Vitamin B6
25.A nurse is assessing for correct placement of a nasogastric tube. The nurse
aspirates the stomach contents and checks the contents for pH. The nurse
verifies correct tube placement if which pH value is noted?
A. 3.5
B. 7.0
C. 7.35
D. 7.5
Answer: A
Rationale: If the nasogastric tube is in the stomach, the pH of the contents
will be acidic. Gastric aspirates have acidic pH values and should be 3.5 or

lower. Option 2 indicates a slightly acidic pH. Option 3 indicates a neutral pH.
Option 4 indicates an alkaline pH.
26.Among the following foods, which has the highest amount of potassium?
A. Baked potato
B. Orange
C. Medium apricot
D. Banana
27.Which of the following provides the richest source of Iron per area of their
meat?
A. Pork meat
B. Lean read meat
C. Pork liver
D. Green mongo
FUNDAMENTAL HUMAN NEEDS: BOWEL/FECAL ELIMINATION
28.What is the duration of a RETENTION enema?
A.5-10 minutes
B.1-3 hours
C.5-10 seconds
D.1-3 minutes
CONCEPT 7: FUNDAMENTAL HUMAN NEEDS: ELIMINATION
***NOTE: ACTUAL BOARD EXAM QUESTION JUNE 2007 NURSING PRACTICE I NLE!
29.The following are appropriate nursing intervention during colostomy irrigation
EXCEPT:
A. Position client in semi-Fowler
B. Insert 2-4 inches of an adequately lubricated catheter to the stoma
C. Increase the irrigating solution flow rate when abdominal cramps is felt
D. Hang the solution 18 inches above the stoma
CORRECT ANSWER: C
ANALYSIS:
OPTION A - Position client in semi-Fowler
**Place client comfortably in any of the following positions in irrigating
colostomy, (place linen saver under client if performing procedure in bed)
On commode
Sitting on chair facing toilet
In side-lying position turned towards the side of stomal opening, with
head of bed elevated 30 to 45 degrees
In supine position
RATIONALE: Provides for effective irrigation
OPTION B - Insert 2-4 inches of an adequately lubricated catheter to the
stoma- Gently insert 3 to 4 inches of irrigation tubing through cone opening
into stoma; if tubing does not ease into opening, do not force

RATIONALE: prevents injury to stomal or bowel tissue


OPTION C - Increase the irrigating solution flow rate when abdominal cramps
is felt If client complains of cramping, STOP the infusion for several
minutes; then resume infusion SLOWLY.
RATIONALE: Allows bowel time to adjust to fluid
OPTION D - Hang the solution 18 inches above the stoma Position irrigation
bag (with tubing attached) at a height of 18 inches above the stoma
(approximately shoulder level)
RATIONALE: Avoids undue pressure on mucosal tissues from rushing of
fluid
OPTIONS A, B and D are correct procedures for irrigating colostomy except
option C.
*Nurses Guide to Clinical Procedures by Lippincott Company Jean SmithTemple and Joyce Young Johnson, 2nd ed. 1994, p. 326-329
Situation Mrs. Seva, 52 years old, asks you about possible problems regarding her
elimination now that she is in the menopausal stage. Refer to question numbers 3034
30.Instruction on health promotion regarding urinary elimination is important.
Which would you include?
A. Hold urine as long as she can before emptying the bladder to strengthen
her sphincter muscles
B. If burning sensation is experienced while voiding, drink pineapple juice
C. After urination, wipe from anal area up towards the pubis
D. Tell client to empty the bladder at each voiding
31.Mrs. Seva also tells the nurse that she is often constipated. Because she is
aging, what physical changes predispose her to constipation?
A. inhibition of the parasympathetic reflex
B. weakness of sphincter muscles of anus
C. loss of tone of the smooth muscles of the colon
D. decreased ability to absorb fluids in the lower intestines
32.The nurse understands that one of these factors contributes to constipation:
A. excessive exercise
B. high fiber diet
C. no regular time for defecation daily
D. prolonged use of laxatives
33.Mrs. Seva talks about fear of being incontinent due to a prior experience of
dribbling urine when laughing or sneezing and when she has a full bladder.
Your most appropriate instruction would be to:
A. tell client to drink less fluids to avoid accidents
B. instruct client to start wearing thin adult diapers

C. ask the client to bring change of underwear just in case


D. teach client pelvic exercise to strengthen perineal muscles
34.Mrs. Seva asked for instructions for skin care for her mother who has urinary
incontinence and is almost always in bed. Your instruction would focus on
prevention of skin irritation and breakdown by:
A. Using thick diapers to absorb urine well
B. Drying the skin with baby powder to prevent or mask the smell of
ammonia
C. Thorough washing, rising and drying of skin area that get wet with urine
D. Making sure that linen are smooth and dry at all times
35.The nurse plans to teach Michiel about colostomy irrigation. As the nurse
prepares the materials needed, which of the following item indicates that the
nurse needs further instruction?
A. Plain NSS / Normal Saline
B. K-Y Jelly
C. Tap water
D. Irrigation sleeve
Rationale: The colon is not sterile, nor the stomach. Tap water is used in
enema irrigation and not NSS. Although some clients would prefer a distilled,
mineral or filtered water, NSS is not
always necessary. KY Jelly is used as the lubricant for the irrigation tube and
is inserted
3-4 inches into the colostomy pointing towards the RIGHT. Irrigation sleeve is
use to
direct the flow of the irrigated solution out of the stomach and into the
bedpan or toilet.
36.The nurse should insert the colostomy tube for irrigation at approximately?
A. 1-2 inches
B. 3-4 inches
C. 6-8 inches
D. 12-18 inches
1
Rationale: Remember 3-4 inches. They are both used in the rectal tube and
colostomy irrigation
2
tube insertion. 1 to 2 inches is too short and may spill out the irrigant out of
the stoma.
3
Starting from 6 inches, it would be too long already and may perforate the
bowel.
4
37.The maximum height of irrigation solution for colostomy is?
A. 5-10 inches
B. 12-18 inches
C. 18-24 inches
D. 24-30 inches

38. An abdomino-perineal resection with a transverse colostomy is planned for


an adult client. Neomycin sulfate p.o. is ordered prior to surgery. The primary
purpose for administering this drug is to reduce:
A. electrolyte imbalances.
B. bacterial content in the colon.
1 C. peristaltic action in the colon.
2 D. feces in the bowel.
3
39.The nurse knew that the normal color of Michiels stoma should be?
A. Beefy Red
B. Gray
C. Blue
D. Pale Pink
Rationale: The stoma should be RED in color. Pale pink are common with
anemic or dehydrated
patients who lost a lot of blood after an operation. Blue stoma indicated
cyanosis or
alteration in perfusion. Stomas are not expected to be Gray.
BLOOD TRANSFUSION
**NOTE: ACTUAL BOARD EXAM QUESTION 2008 NLE!
SITUATION: Maxima, an ER nurse is preparing her equipments for blood transfusion
to a patient who has massive bleeding due to vehicular accidents. Refer to question
numbers 40-42
40.The only solution compatible during blood transfusion?
A.Lactated ringers
B.Balance multiple solution
C.Normal saline
D.Tap water
41.The KVO rate of BT is?
A.30 gtts/min
B.20 gtts/min
C.10 gtts/min
D.100 gtts/min
42.Following surgery, the client requires a blood transfusion. The main reason
the nurse wants to complete the unit transfusion within a four-hour period
that blood:
A. Hanging for longer than 4 hours creates an increased risk of sepsis
B. May clot in the bag
C. May evaporate
D. May not clot in the recipient after this time period
Situation - As a nurse you have to be prepared to care for patients receiving blood
transfusion. The physician has ordered 3 units of whole blood to be transfused to

Diego following a repair of a dissecting aneurysm of the aorta. Refer to question


numbers 43-46
43.You are preparing a unit of whole blood for transfusion. From the time you
obtain it from the blood blank how long should you infuse it?
A. 4 hours
B. 1 hour
C. 2 hours
D. 6 hours

1.
2.

3.

4.

6.

Rationale:
Procedure for blood transfusion :
Identify the patient by asking the patient their name and date of birth while
comparing it to the hospital ID band. Ensure the Blood ID Band is on the
patients wrist as this band has their unique R identifier number on it.
The patient should be assessed prior to requesting blood products.
Assessment should include temperature. If oral temperature is 100 degrees
Fahrenheit or higher, clarify with patients physician whether or not to
proceed with the transfusion.
Verify that blood product received is product that was ordered. Refer to Blood
and Blood Components Identification (blo02) to verify that the blood
product received is in date, is labeled for the intended patient, has been
crossmatched for the intended patient, and that all identifying information on
the product bag tag corresponds with the information on the patients band.
In the case of autologous blood, and if the patient is able, ask the patient to
state his/her social security number on the blood unit label. Two nurses, one
of whom is an RN, must verify the ordering information against the delivered
product, and the identification of the patient. The unique R number on the
pink Blood ID band must match the R number on the blood bag tag. DO
NOT PROCEED WITH THE TRANSFUSION IF THESE R NUMBERS DO NOT
MATCH.
If there is a problem with identification of the blood component, return the
component to the blood bank immediately.
5. Document on the bag tag, the date, the time the unit was started, the
patients vital signs and the signatures of the transfusionist and verifying
nurse.
NOTE: Take and document the patients vital signs before the transfusion, 10
minutes after initiating the transfusion and upon completion of the
transfusion. Vital signs should be taken more often whenever indicated.
Document any abnormal
findings.
For gravity infusion, verify that the Y tubing of the blood set has been
primed with saline. Using aseptic technique, attach the blood bag to the
other side of the Y tubing. Clamp tubing on saline side and open clamp on
blood bag side to allow blood to infuse.

7. For electronic controller infusion, verify that the primary set has been primed
with normal saline as well as the blood secondary set. Using aseptic
technique, attach the blood bag to the secondary blood set and connect the

secondary port at the cassette.


8. Begin infusing blood slowly at no greater than 2ml/min (blood tubing is 10
drops/ml so 2 ml/min equals 20 drops per minute which equates to 120
ml/hour on the electronic controller). Remain with the patient while the first
15 to 30 ml of blood infuses. During this time, observe patient closely for
signs of complications.
9. Assess the patient ten minutes after initiating the transfusion, including
vital signs. Document any abnormal findings. If patient is tolerating the
transfusion and no signs of reaction are observed, the rate of infusion may be
increased to a rate the patient can tolerate.
10. After increasing the infusion rate, remain with the patient while the next
20 to 30 ml of blood infuses.
11. Observe the patient during the transfusion at least every thirty minutes,
or more often if indicated. Verify that the blood is infusing continually. Adjust
drip rate as needed and according to the patients currentcondition.
NOTE: A unit of blood must be infused within four (4)hours. (CORRECT
ANSWER) Options B, C and D if not lacking but exceed the time allowed for
blood transfusion and it may cause any adverse reactions if it exceeds 4
hours.
12. Transfuse blood completely. Flush with normal saline to clear
tubing.
13. Change the blood tubing as follows:
a. After the saline flush this follows the blood transfusion.
b. Between units of multiple transfusions if the total tubing use time
will exceed four hours.
CAUTION NOTE: The risk of hemolysis and bacterial contamination rises
dramatically after
four hours from the presence of residual blood in the tubing.
c. If clots develop or the filter clogs.
14. Continue with patients previous intravenous orders, insert a PRN Adapter
or discontinue the access as appropriate to the patients orders.
15. Following transfusion, complete the bag tag, including the time the unit is
finished, patients vital signs and volume transfused. Remove bag tag from
the bag and attach to the laboratory mounting form in the chart.
16. Place the empty blood bag and used tubing in a biohazardous waste bag
and take to the Soiled Utility Room and dispose of in a waste container
designated for biohazardous waste. These containers will be lined with red
plastic bags.
NOTE: If a second unit is being administered and the tubing is not being
changed, plug the open port of the empty blood bag with a needle cap before
discarding the bag
(http://www.smh.com/sections/servicesprocedures/medlib/nursing/Procedures
/Blood/AdminRed_blo03_112105.pdf)
44.As Diegos nurse what will you do after the transfusion has been started?
A. Discontinue the primary IV of Dextrose 5% water
B. Stay with Diego for 15 minutes to note for any possible BT reaction
C. Check his vital signs every 15 minutes

D. Add the total amount of the blood to be transferred to the intake and
output
Answer: B
Rationale: Monitor and document vital signs every 5 minutes for the first 15
minutes assessing for chilling, back pain, head ache, nausea or vomiting,
tachycardia, hypotension, tachypnea, or skin rash. Altered vital signs or
other adverse reactions are early indications of a transfusion reaction.
Infusing blood slowly during this period limits the amount of blood the client
receives if there is a reaction.
Reference: Craven, Ruth F. & Constance J. Hirnle, Fundamentals of Nursing:
Human Health and Function, Lippincott Williams &Wilkins, 4 th ed. 2003 page
605
45.Diego is undergoing blood transfusion of the first unit. The earliest signs of
transfusion reactions are
A. Oliguria and jaundice
B. Urticaria and wheezing
C. Hypertension and flushing
D. Headache, chills and fever
Answer: D
Rationale: Acute transfusion reactions present as adverse signs or symptoms
during or within 24 hours of a blood transfusion. The most frequent reactions
are fever, chills, urticaria, or shortness of breath, which resolve promptly
without specific treatment or complications. More serious reactions, such as
hemolysis or sepsis, are potentially fatal.
Transfusion reactions require immediate recognition, laboratory
investigation, and clinical management. If a transfusion reaction is suspected
during blood administration, the safest practice is to stop the transfusion and
keep the intravenous line open with 0.9% sodium chloride (normal saline). A
clerical check of the blood unit label and patient should be performed. In
most cases, the blood product should be returned to the blood bank, and a
transfusion reaction investigation should be initiated.
Acute transfusion reactions may present in complex clinical situations when
diagnosis requires distinguishing between a reaction to the transfused blood
product and a coincidental complication of the illness being treated that
occurs during or immediately after a blood transfusion.
In option C, hypertension rarely exists in transfusion reaction, instead there is
HYPOTENSION as a part of anaphylactic reaction of the body to transfusion of
blood.
(http://www.emedicine.com/med/topic2297.htm)
46.In case Diego will experience an acute haemolytic reaction, what will be your
priority intervention?
A. Immediately stop the blood transfusion, infuse Dextrose 5% in
water and call the physician
B. Slow the blood transfusion and monitor the patient closely

C. Immediately stop the blood transfusion, notify the blood bank and
administer antihistamines
D. Immediately stop the blood transfusion, infuse normal saline
solution, call the physician, notify the blood bank
Answer: D
Rationale: Acute hemolytic reaction
- most serious among acute transfusion reactions and can be life
threatening. occurs when the donors blood is incompatible with the
recipients blood
- always monitor vital signs before starting the infusion and during the first
five minutes when the blood is infusing slowly. If you suspect a hemolytic
reaction, stop the transfusion immediately and keep the IV open with
normal saline.
Reference: Craven, Ruth F. & Constance J. Hirnle, Fundamentals of Nursing:
Human Health and Function, Lippincott Williams &Wilkins, 4 th ed. 2003 page
607
47.Which of the following is the correct procedure in transfusing Fresh Frozen
Plasma?
A.Confirm doctors order after gathering materials
B.Get baseline vital signs after the transfusion
C.Administer Fresh Frozen Plasma for the first 15 minutes, then transfuse
according to the computed rate if there will be no adverse reaction
D.Administer Fresh Frozen Plasma immediately
FLUIDS AND ELECTROLYTES
48.The nurse assesses a client to be experiencing muscle cramps, numbness,
and tingling of the extremities, and twitching of the facial muscle and eyelid
when the facial nerve is tapped. The nurse reports this assessment as
consistent with which of the following?
A. Hypokalemia
B. Hypernatremia
C. Hypermagnesemia
D.Hypocalcemia
49.The nurse writes the nursing problem of fluid volume excess (FVE). Which
intervention should be included in the plan of care?
A.Change the IV fluid from 0.9% NSS to D5W
B.Restrict the clients sodium in the diet.
C.Monitor blood glucose level
D.Prepare the client for hemodialysis
50.The client has been vomiting and has had numerous episodes of diarrhea.
Which laboratory test should the nurser monitor?
A.Serum Calcium
B.Serum Phosphorus
C.Serum potassium

D.Serum sodium