NR-324 Adult Health I - Set 4 - Part 1

Correct Answer: Your hemoglobin should rise about one point and your symptoms should ease.

One unit of packed red cells raises the hemoglobin by roughly one gram per deciliter and the hematocrit by about three percent. Success means relief of symptoms and a level above the threshold, not a normal value. Option b is incorrect because a restrictive strategy aims for a level above the transfusion threshold rather than the reference range. One unit moves a hemoglobin of about six point six to roughly seven point six. Option c is incorrect because the hematocrit climbs only about three percent per unit, not to twice its starting value. Expecting a doubling would lead the team to judge an adequate transfusion a failure. Option d is incorrect because the monitoring that matters during the infusion is the client, meaning vital signs, temperature and respiratory status. The hemoglobin is drawn after the unit finishes, not while it runs.

Correct Answer: Measuring and recording the routine vital signs

Unlicensed personnel may measure and record vital signs for a stable client, with the nurse interpreting the values and staying responsible for the assessment. The tasks that require nursing judgment are not delegated during a transfusion. Option a is incorrect because the identity and product check must be done by two qualified professionals, which policy defines as registered nurses in most settings. This step exists precisely to prevent a fatal misidentification. Option b is incorrect because auscultation is an assessment, and new crackles are the finding that separates circulatory overload from other reactions. Interpreting breath sounds sits squarely within the nurse's own scope of practice. Option c is incorrect because setting the rate of a blood product is a nursing responsibility tied to the client's tolerance and the four hour limit. Unlicensed staff do not titrate any infusion.

Correct Answer: Its calcium overwhelms the citrate and clots the line

Stored red cells are anticoagulated with citrate, which works by binding calcium. Lactated Ringer's contains calcium, and when it exceeds what the citrate can bind the freed calcium lets clots form inside the intravenous line. Option b is incorrect because the lactate in this solution is converted to bicarbonate and actually tends to raise the pH. Acid damage to the cells is not the reason the solution is avoided. Option c is incorrect because the small amount of potassium in a liter of this fluid is not what bars it from a blood line. The objection is a divalent cation interacting with the unit's preservative. Option d is incorrect because this solution is isotonic and does not drive water into red cells. Swelling and rupture from a hypotonic environment describe what dextrose in water does, not what Ringer's does.

Correct Answer: Group O negative packed red blood cells

Group O negative red cells carry no A antigen, no B antigen and no D antigen, so there is nothing on them for any recipient antibody to attack. That makes them the emergency release product. Option a is incorrect because group AB red cells display both the A and the B antigen. They are the universal recipient type, not the universal donor, and would be destroyed in most recipients. Option b is incorrect because cells carrying the A antigen would be attacked by antibodies against A present in any client of group B or group O. Emergency blood must be antigen free. Option d is incorrect because the B antigen on these cells is a target for the antibodies carried by group A and group O clients. Only the absence of both antigens makes a unit universally safe.

Correct Answer: Build fiber back up slowly with fluids

Fiber is withheld only while the diverticula are inflamed. Once the flare settles, a high fiber pattern is rebuilt gradually with generous fluid, because bulky soft stool lowers pressure inside the sigmoid colon. Option a is incorrect because clear liquids are nutritionally inadequate beyond a few days and are meant only for the acute episode. Staying on them for months would produce deficiency without preventing another attack. Option b is incorrect because a low fiber pattern is the flare treatment, not the prevention plan. Long term restriction leaves stool small and hard, raising intraluminal pressure and encouraging the very inflammation being avoided. Option c is incorrect because fruits and vegetables are the mainstay of the recommended pattern, along with reduced fat and red meat. Permanent avoidance of produce contradicts the prevention advice for diverticular disease.

Correct Answer: A brisk upper bleed is likely

Hematochezia usually means a lower source, but a vigorous upper bleed can move blood through too fast to be digested. Tachycardia, hypotension and pallor with an ulcer history point to massive upper hemorrhage. Option a is incorrect because hemorrhoids bleed in small streaks or drips and do not drop the blood pressure. A client this unstable is losing far more volume than an anorectal vein can supply. Option b is incorrect because diverticular bleeding is painless and often brisk, yet the known ulcer and the profound hemodynamic change make an upper source far more probable here. Diverticular bleeding frequently stops on its own. Option d is incorrect because ischemic colitis typically brings crampy left sided abdominal pain with modest bleeding in an older client with vascular disease. Painless massive bleeding in an ulcer client fits a different source.

Correct Answer: Those foods no longer need to be avoided

Current evidence does not support avoiding nuts, seeds or popcorn in diverticular disease, and the older restriction has been withdrawn. These foods belong to the high fiber pattern that prevention actually depends upon. Option b is incorrect because the idea that particles lodge in diverticula and set off inflammation was never demonstrated. Prospective study found no association between nut, seed or popcorn intake and diverticular complications. Option c is incorrect because lifelong avoidance gives no protection and removes fiber rich foods from the diet. What does lower risk is a high fiber pattern, weight control and regular physical activity. Option d is incorrect because no single food on that old list has been singled out as harmful. Popcorn, nuts and seeds are treated alike, and all three are acceptable outside an acute flare.

Correct Answer: Neither is safe, because both can hasten rupture

Laxatives and enemas raise peristalsis and intraluminal pressure in an already distended appendix, and heat increases local blood flow and inflammation. Both are believed to hasten rupture, so the client stays nothing by mouth. Option a is incorrect because heat is the half that is often overlooked. Warmth increases blood flow to the inflamed appendix and worsens the inflammation, so an ice bag is used instead when comfort measures are ordered. Option b is incorrect because an enema carries the same hazard as an oral cathartic. Distending the colon and driving peristalsis raises pressure around an appendix that is already obstructed and ischemic. Option c is incorrect because nothing that moves the bowel or warms the abdomen belongs in care before the diagnosis is settled. Standard practice also keeps the client nothing by mouth in case surgery follows.

Correct Answer: Elevate the entire head of the bed

Elevating the whole head of the bed about thirty degrees, or six to eight inches on blocks, keeps the esophagus above the stomach overnight. Pillows alone flex the trunk and raise abdominal pressure, worsening reflux. Option a is incorrect because extra pillows raise only the head and neck, bending the trunk forward and increasing intra abdominal pressure. That combination pushes gastric contents upward and can make night time reflux worse. Option b is incorrect because lying flat removes the gravity that keeps refluxate in the stomach. Side lying position alone does not raise the esophagus above the gastresophageal junction, so acid still pools against unprotected squamous mucosa. Option d is incorrect because raising the foot of the bed tilts the stomach above the esophagus and encourages reflux. The head end is the end that must come up for gravity to help.

Correct Answer: Before starting, at fifteen minutes, hourly, and at completion

Vital signs are taken before the transfusion starts to give a baseline, again at fifteen minutes when reactions are most likely, hourly through the remainder of the infusion, and once more when the unit is complete. Option b is incorrect because it omits the fifteen minute set, which is the single most important reading of the transfusion. It also drops the hourly checks that catch a reaction developing later in the unit. Option c is incorrect because half hourly readings are more frequent than the accepted schedule and still miss the required baseline taken before anything is hung. Extra readings do not compensate for a missing starting point. Option d is incorrect because a first reading two hours into the unit arrives long after the window in which most reactions declare themselves. By then a hemolytic reaction could already be well established.

Correct Answer: Routine clotting studies are not needed for either

Low molecular weight heparin has a predictable response and needs no routine aPTT, and the direct oral anticoagulants need no routine coagulation testing either. Renal function is checked periodically for both. Option a is incorrect because weekly clotting times would impose testing that neither of these agents requires. Fixed or weight based dosing of enoxaparin was developed precisely to avoid that burden on the client. Option b is incorrect because the INR tracks warfarin, which depletes the vitamin K dependent factors. Freedom from that testing and from dietary restriction is why apixaban has largely displaced warfarin. Option c is incorrect because that test belongs to unfractionated heparin given by continuous infusion. Enoxaparin is measured with an anti factor Xa level only in pregnancy, obesity or renal impairment.

Correct Answer: Stop the transfusion of the blood product

These findings describe an acute hemolytic reaction from incompatible blood. Stopping the transfusion comes before anything else, because the severity tracks the volume infused and every additional milliliter makes the hemolysis, renal injury and shock worse. Option a is incorrect because vital signs are part of the assessment that follows, not what comes first. Measuring a blood pressure while incompatible cells keep running adds to the dose the client receives. Option c is incorrect because notification is the fourth step in the sequence. The provider directs treatment and the blood bank checks for a second mislabeled unit, but both calls happen after the infusion is halted. Option d is incorrect because returning the bag, tubing and labels belongs to the later investigation. Nothing is sent anywhere while blood is still entering the client and the reaction is still building.

Correct Answer: Hold the infusion and prepare protamine sulfate

Heparin is monitored by the activated partial thromboplastin time, and its antidote is protamine sulfate. With the value supratherapeutic and the client bleeding, the infusion is held and reversal is prepared. Option b is incorrect because phytonadione reverses warfarin by restoring the vitamin needed to build factors two, seven, nine and ten. It has no effect on a drug that works through antithrombin. Option c is incorrect because leaving the drug running while the client is already bleeding allows the excess anticoagulation to continue. Redrawing a level documents the problem without doing anything about it. Option d is incorrect because plasma replaces missing clotting factors, and this client has plenty of factors that are simply being inhibited. Neutralizing the circulating drug is what will stop the oozing.

Correct Answer: The unit labeled O negative red cells

A B negative client carries antibodies against A, so no donor cell may display the A antigen, and lacks the D antigen, so no unit may be Rh positive. Only B negative and O negative units qualify. Option a is incorrect because the ABO group is acceptable but the Rh type is not. Giving D positive cells to an Rh negative client sensitizes them and risks hemolysis on any future transfusion. Option b is incorrect because matching the ABO letter is not enough when the client lacks the D antigen. This unit is Rh positive, and the same sensitization risk applies to it as to any D positive product. Option d is incorrect because the Rh type is correct but the A antigen is not. This client's plasma contains antibodies against A, which would destroy the donor cells and produce an acute hemolytic reaction.

Correct Answer: I will sit him up for the feeding and an hour afterward.

The head of the bed is raised for the feeding and kept up for at least an hour afterward, because formula remaining in the stomach can still reflux once the client lies down. Option a is incorrect because the upright position must be in place before the formula runs, not established afterward. Sitting him up at the end does nothing about the volume already delivered flat. Option c is incorrect because lying flat during a feeding removes gravity from the one place it helps, allowing formula to pool at the gastro esophageal junction and spill into the pharynx. Option d is incorrect because the stomach is still full when a feeding ends. Lowering the bed immediately is the moment of greatest reflux risk, which is why the elevation is held afterward.

Correct Answer: Keep the client nothing by mouth

Resting the bowel is the first therapeutic goal in an acute flare, and keeping the client nothing by mouth is the independent nursing action that achieves it while drug and fluid orders are obtained. Option a is incorrect because any oral intake contradicts bowel rest during a flare. A full liquid diet also carries dairy, which many clients with inflammatory bowel disease tolerate poorly, so it is specifically withheld. Option b is incorrect because the client already has profuse diarrhea. Increasing motility in a severely inflamed colon raises the risk of toxic megacolon and perforation, which is why softeners are contraindicated in this situation. Option c is incorrect because a corticosteroid is what the nurse anticipates the provider ordering, not what the nurse does first. It controls inflammation, yet bowel rest precedes it and requires no prescription.

Correct Answer: Intramuscular epinephrine with airway and oxygen support

Wheezing, lip swelling and shock minutes into a plasma product describe anaphylaxis, classically an immunoglobulin A deficient recipient reacting to donor plasma. Epinephrine is the treatment, with airway support, oxygen, fluids, bronchodilators and corticosteroids. Option a is incorrect because an antipyretic treats the febrile non hemolytic reaction, in which fever and chills appear without airway or circulatory collapse. Acetaminophen does nothing for bronchospasm or a falling blood pressure. Option b is incorrect because a diuretic belongs to circulatory overload, where the pressure rises and the neck veins distend. Removing fluid from a client already in shock would drive the blood pressure lower still. Option d is incorrect because an antihistamine by itself suits the mild urticarial reaction, where the client has hives and itching but remains otherwise well. It cannot reverse bronchospasm, laryngeal swelling or shock.

Correct Answer: Gastresophageal reflux disease from sphincter failure

Burning substernal pain that appears after a meal and worsens lying flat or bending over is the cardinal reflux picture. Gravity no longer holds gastric contents down once the lower esophageal sphincter loses its pressure advantage. Option b is incorrect because duodenal ulcer pain comes two to five hours after eating, is relieved by food or antacids, and characteristically wakes the client at night rather than tracking with posture. Option c is incorrect because paralytic ileus follows abdominal surgery or peritonitis and presents with distention, absent bowel sounds and no stool passage. Substernal burning tied to meals and posture is not part of that picture. Option d is incorrect because appendicitis begins with vague periumbilical pain that migrates to the right lower quadrant, joined by anorexia, fever and rebound tenderness. Lying down does not intensify it the way reflux is intensified.

Correct Answer: A crushed extended release tablet mixed with water

Extended release preparations depend on an intact matrix to control the rate of drug release. Crushing one delivers the entire dose at once, so the order must be clarified and another form requested. Option a is incorrect because a liquid preparation is exactly what is preferred for tube administration. Potassium chloride is diluted before instillation to reduce mucosal irritation, and that is already specified here. Option b is incorrect because an elixir passes through the lumen without clumping, and flushing afterward clears residue that would otherwise dry and block the tube. This order follows recommended practice. Option c is incorrect because an immediate release tablet has no coating or matrix to destroy. Crushing it finely and mixing it with water is an accepted method when no liquid form exists.

Correct Answer: Emptying the pouch and recording output

Emptying a pouch and recording the volume is a routine, standardized task within assistive personnel scope. Assessment of stoma color, evaluation of the appliance seal and client teaching stay with the registered nurse. Option a is incorrect because stoma color is the perfusion assessment that identifies ischemia, and assessment is never delegated. A dusky change must be recognized and acted on by a licensed nurse. Option b is incorrect because teaching is a nursing function that requires assessing readiness and evaluating understanding. This client must learn to drink at least three liters daily and to avoid enteric coated medications. Option d is incorrect because judging the fit of a skin barrier requires evaluation of peristomal skin and of how the appliance is performing. Evaluation belongs to the nurse, not to unlicensed staff.