NUR104 | NUR104 Medsurg 2 Exam 3 Version 3
Questions with Correct Answers and Expert
Explanation for Each Question
1. A nurse is monitoring a patient receiving a unit of packed red blood cells (PRBCs)
who suddenly complains of lower back pain and chills. Which action should the nurse
take first?
A. Stop the transfusion and disconnect the blood tubing from the IV site.
B. Slow the infusion rate and notify the physician.
C. Administer an antipyretic as ordered for the chills.
D. Reposition the patient to relieve the back pain.
Correct Answer: A
Expert Explanation: Lower back pain and chills are classic signs of an acute
hemolytic transfusion reaction which is a life-threatening emergency. The first
priority is to stop the infusion immediately to prevent further exposure to the
incompatible blood. After stopping the blood, the nurse should run normal saline
through new tubing to keep the vein open. Vital signs must be monitored closely
while notifying the healthcare provider and blood bank. This sequence of
interventions ensures patient safety and stabilizes the circulatory system during a
crisis.
,2. A patient with chemotherapy-induced neutropenia is being cared for on a medical
unit. Which nursing intervention is most appropriate to prevent infection?
A. Allow the patient to have fresh fruit brought from home.
B. Instruct the patient to use a soft toothbrush for oral care.
C. Maintain the patient in a negative-pressure room.
D. Perform frequent hand hygiene and restrict visitors with respiratory infections.
Correct Answer: D
Expert Explanation: Neutropenia significantly reduces the body’s ability to fight off
pathogens making the patient highly susceptible to infections. Hand hygiene is the
single most effective way to prevent the spread of microorganisms in clinical
settings. Restricting ill visitors further decreases the risk of community-acquired
viral or bacterial transmission. While oral care is important, it primarily addresses
mucosal integrity rather than systemic infection prevention in this context. These
combined actions provide a protective environment for the immunocompromised
patient.
3. A client is diagnosed with Pernicious Anemia. The nurse understands that this
condition is caused by a deficiency in which substance?
A. Intrinsic factor
B. Iron
,C. Erythropoietin
D. Folic acid
Correct Answer: A
Expert Explanation: Pernicious anemia occurs when the gastric mucosa fails to
produce intrinsic factor which is necessary for Vitamin B12 absorption. Without
Vitamin B12, red blood cells cannot mature properly leading to macrocytic anemia
and neurological issues. Patients with this condition usually require lifelong Vitamin
B12 injections because oral supplements are not absorbed. The nurse must educate
the patient on the chronic nature of the disease and the importance of adherence to
therapy. Monitoring for paresthesia and gait changes is also a critical nursing
responsibility.
4. A nurse is assessing a patient for suspected Disseminated Intravascular Coagulation
(DIC). Which clinical finding most strongly suggests this condition?
A. Bleeding from invasive sites and petechiae.
B. Elevated platelet count and hypertension.
C. Bradycardia and increased urinary output.
D. Painful swelling in a single lower extremity.
Correct Answer: A
, Expert Explanation: DIC is a complex disorder where clotting and bleeding occur
simultaneously due to the depletion of clotting factors. Oozing from IV sites, mucosal
bleeding, and the appearance of petechiae are hallmark signs of consumptive
coagulopathy. The underlying cause must be identified and treated to stop the
abnormal clotting cascade. Laboratory results typically show prolonged clotting
times and elevated D-dimer levels. Early recognition is vital to prevent multi-organ
failure and ensure timely administration of blood products.
5. During a blood transfusion, the patient develops generalized urticaria and itching.
What is the most likely type of reaction occurring?
A. Febrile non-hemolytic reaction
B. Allergic reaction
C. Circulatory overload
D. Septic reaction
Correct Answer: B
Expert Explanation: Urticaria and pruritus indicate a hypersensitivity or allergic
reaction to plasma proteins in the donor blood. If the reaction is mild and localized,
the physician may order an antihistamine and resume the transfusion slowly.
However, the nurse must always stop the infusion initially to assess the severity of
the symptoms. Monitoring for respiratory distress is essential as allergic reactions
Questions with Correct Answers and Expert
Explanation for Each Question
1. A nurse is monitoring a patient receiving a unit of packed red blood cells (PRBCs)
who suddenly complains of lower back pain and chills. Which action should the nurse
take first?
A. Stop the transfusion and disconnect the blood tubing from the IV site.
B. Slow the infusion rate and notify the physician.
C. Administer an antipyretic as ordered for the chills.
D. Reposition the patient to relieve the back pain.
Correct Answer: A
Expert Explanation: Lower back pain and chills are classic signs of an acute
hemolytic transfusion reaction which is a life-threatening emergency. The first
priority is to stop the infusion immediately to prevent further exposure to the
incompatible blood. After stopping the blood, the nurse should run normal saline
through new tubing to keep the vein open. Vital signs must be monitored closely
while notifying the healthcare provider and blood bank. This sequence of
interventions ensures patient safety and stabilizes the circulatory system during a
crisis.
,2. A patient with chemotherapy-induced neutropenia is being cared for on a medical
unit. Which nursing intervention is most appropriate to prevent infection?
A. Allow the patient to have fresh fruit brought from home.
B. Instruct the patient to use a soft toothbrush for oral care.
C. Maintain the patient in a negative-pressure room.
D. Perform frequent hand hygiene and restrict visitors with respiratory infections.
Correct Answer: D
Expert Explanation: Neutropenia significantly reduces the body’s ability to fight off
pathogens making the patient highly susceptible to infections. Hand hygiene is the
single most effective way to prevent the spread of microorganisms in clinical
settings. Restricting ill visitors further decreases the risk of community-acquired
viral or bacterial transmission. While oral care is important, it primarily addresses
mucosal integrity rather than systemic infection prevention in this context. These
combined actions provide a protective environment for the immunocompromised
patient.
3. A client is diagnosed with Pernicious Anemia. The nurse understands that this
condition is caused by a deficiency in which substance?
A. Intrinsic factor
B. Iron
,C. Erythropoietin
D. Folic acid
Correct Answer: A
Expert Explanation: Pernicious anemia occurs when the gastric mucosa fails to
produce intrinsic factor which is necessary for Vitamin B12 absorption. Without
Vitamin B12, red blood cells cannot mature properly leading to macrocytic anemia
and neurological issues. Patients with this condition usually require lifelong Vitamin
B12 injections because oral supplements are not absorbed. The nurse must educate
the patient on the chronic nature of the disease and the importance of adherence to
therapy. Monitoring for paresthesia and gait changes is also a critical nursing
responsibility.
4. A nurse is assessing a patient for suspected Disseminated Intravascular Coagulation
(DIC). Which clinical finding most strongly suggests this condition?
A. Bleeding from invasive sites and petechiae.
B. Elevated platelet count and hypertension.
C. Bradycardia and increased urinary output.
D. Painful swelling in a single lower extremity.
Correct Answer: A
, Expert Explanation: DIC is a complex disorder where clotting and bleeding occur
simultaneously due to the depletion of clotting factors. Oozing from IV sites, mucosal
bleeding, and the appearance of petechiae are hallmark signs of consumptive
coagulopathy. The underlying cause must be identified and treated to stop the
abnormal clotting cascade. Laboratory results typically show prolonged clotting
times and elevated D-dimer levels. Early recognition is vital to prevent multi-organ
failure and ensure timely administration of blood products.
5. During a blood transfusion, the patient develops generalized urticaria and itching.
What is the most likely type of reaction occurring?
A. Febrile non-hemolytic reaction
B. Allergic reaction
C. Circulatory overload
D. Septic reaction
Correct Answer: B
Expert Explanation: Urticaria and pruritus indicate a hypersensitivity or allergic
reaction to plasma proteins in the donor blood. If the reaction is mild and localized,
the physician may order an antihistamine and resume the transfusion slowly.
However, the nurse must always stop the infusion initially to assess the severity of
the symptoms. Monitoring for respiratory distress is essential as allergic reactions
