Saunders Comprehensive Review for the NCLEX-RN Examination Silvestri 5th Edition Test Bank 8


bases. The nurse determines that this client is most likely experiencing which of the following complications of blood transfusion therapy? 1. Bacteremia 2. Fluid overload 3. Hypervolemic shock 4. Allergic transfusion reaction


ANS: 2


Rationale:With fluid overload, the client has the presence of crackles in the lungs in addition to dyspnea. Other clinical manifestations include hypertension, a bounding pulse, distended jugular veins, restlessness, and confusion. “Bacteremia,” “hypervolemic shock,” and “allergic transfusion reaction” are not associated with the manifestations noted in the question.


Test-Taking Strategy: Note the strategic words “most likely.” Because there is no such thing as hypervolemic shock, “hypervolemic shock” should be eliminated immediately. Eliminate “bacteremia” next because with bacteremia, the client should have fever, which is not part of the clinical picture presented. An allergic transfusion reaction would produce symptoms such as bronchospasm, resulting in dyspnea, itching, and a generalized rash. If needed, review the complications of blood transfusion therapy.


PTS: 1 DIF: Level of Cognitive Ability: Analyzing REF: Ignatavicius, D., &Workman, M. (2010). Medical-surgical nursing: patient- centered collaborative care (6th ed.). St. Louis: Saunders. OBJ: Client Needs: Physiological Integrity TOP: Content Area: Nursing Sciences MSC: Integrated Process: Nursing Process—Assessment


11. A unit of packed red blood cells (PRBCs) was just received from the blood bank for transfusion to an assigned client. The nurse is careful to select tubing especially made for blood products, knowing that this tubing is manufactured with which of the following features? 1. An air vent 2. An in-line filter 3. A microdrip chamber 4. Tinted tubing to protect the blood from light


ANS: 2


Rationale: The tubing used for blood administration has an in-line filter. This helps ensure that any particles larger than the size of the filter are caught in the filter and are not infused into the client. The tubing should be macrodrip, not microdrip, to allow blood to flow freely through the drip chamber. An air vent is unnecessary because the blood bag is not made of glass. “Tinted tubing to protect the blood from light” is incorrect; blood does not need to be protected from light.


Saunders Comprehensive Review for the NCLEX-RN Examination Silvestri 5th Edition Test Bank


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