NUR185/NUR 185 Exam 4 V2 | Concepts of
Adult Health Nursing for the Practical
Nurse II Q&A with Rationale | Hondros
College of Nursing
1. A nurse is caring for a patient receiving a blood transfusion. Within the first 15 minutes, the
patient reports itching and has hives. What is the priority nursing action?
A. Slow the infusion rate
B. Stop the infusion immediately
C. Administer diphenhydramine
D. Notify the healthcare provider
Correct Answer: B
Rationale: The patient is exhibiting signs of an allergic transfusion reaction, which
requires an immediate cessation of the blood product. The nurse must stop the infusion
and keep the vein open with normal saline using new tubing. Only after stopping the
infusion should the nurse notify the provider and the blood bank for further investigation.
2. When assessing a patient with iron-deficiency anemia, which clinical manifestation should
the nurse expect to find?
A. Jaundice of the sclera
B. Beefy red tongue
,C. Spooning of the fingernails
D. Petechiae on the chest
Correct Answer: C
Rationale: Spooning of the nails, also known as koilonychia, is a characteristic sign of
chronic iron deficiency anemia. Other common findings include pallor, fatigue, and
glossitis. Jaundice is more common in hemolytic anemias, while a beefy red tongue is
classic for Vitamin B12 deficiency.
3. A patient with sickle cell anemia is admitted in a vaso-occlusive crisis. Which intervention is
the highest priority for the nurse to implement?
A. Administering oral iron supplements
B. Applying cold compresses to joints
C. Providing aggressive intravenous hydration
D. Encouraging vigorous exercise
Correct Answer: C
Rationale: Hydration is critical in a sickle cell crisis to reduce blood viscosity and prevent
further sickling of red blood cells. Oxygen therapy and pain management are also vital
components of care for these patients. Cold compresses should be avoided as they cause
vasoconstriction, which can worsen the occlusion.
, 4. A nurse is reviewing the lab results for a patient with thrombocytopenia. Which platelet
count would require the nurse to initiate bleeding precautions?
A. 150,000/mm3
B. 45,000/mm3
C. 300,000/mm3
D. 450,000/mm3
Correct Answer: B
Rationale: A normal platelet count ranges from 150,000 to 400,000/mm3.
Thrombocytopenia occurs when the count falls below 150,000, but bleeding precautions
are typically strict when it drops below 50,000/mm3. The nurse must monitor for bruising,
hematuria, and occult blood in the stool at this level.
5. A patient diagnosed with pernicious anemia asks why they must receive vitamin B12
injections rather than oral tablets. Which response by the nurse is correct?
A. The liver cannot process oral vitamin B12 in your condition.
B. Oral tablets are too expensive for long-term therapy.
C. The stomach is missing the intrinsic factor needed for absorption.
D. Injections work faster to cure the anemia permanently.
Correct Answer: C
Adult Health Nursing for the Practical
Nurse II Q&A with Rationale | Hondros
College of Nursing
1. A nurse is caring for a patient receiving a blood transfusion. Within the first 15 minutes, the
patient reports itching and has hives. What is the priority nursing action?
A. Slow the infusion rate
B. Stop the infusion immediately
C. Administer diphenhydramine
D. Notify the healthcare provider
Correct Answer: B
Rationale: The patient is exhibiting signs of an allergic transfusion reaction, which
requires an immediate cessation of the blood product. The nurse must stop the infusion
and keep the vein open with normal saline using new tubing. Only after stopping the
infusion should the nurse notify the provider and the blood bank for further investigation.
2. When assessing a patient with iron-deficiency anemia, which clinical manifestation should
the nurse expect to find?
A. Jaundice of the sclera
B. Beefy red tongue
,C. Spooning of the fingernails
D. Petechiae on the chest
Correct Answer: C
Rationale: Spooning of the nails, also known as koilonychia, is a characteristic sign of
chronic iron deficiency anemia. Other common findings include pallor, fatigue, and
glossitis. Jaundice is more common in hemolytic anemias, while a beefy red tongue is
classic for Vitamin B12 deficiency.
3. A patient with sickle cell anemia is admitted in a vaso-occlusive crisis. Which intervention is
the highest priority for the nurse to implement?
A. Administering oral iron supplements
B. Applying cold compresses to joints
C. Providing aggressive intravenous hydration
D. Encouraging vigorous exercise
Correct Answer: C
Rationale: Hydration is critical in a sickle cell crisis to reduce blood viscosity and prevent
further sickling of red blood cells. Oxygen therapy and pain management are also vital
components of care for these patients. Cold compresses should be avoided as they cause
vasoconstriction, which can worsen the occlusion.
, 4. A nurse is reviewing the lab results for a patient with thrombocytopenia. Which platelet
count would require the nurse to initiate bleeding precautions?
A. 150,000/mm3
B. 45,000/mm3
C. 300,000/mm3
D. 450,000/mm3
Correct Answer: B
Rationale: A normal platelet count ranges from 150,000 to 400,000/mm3.
Thrombocytopenia occurs when the count falls below 150,000, but bleeding precautions
are typically strict when it drops below 50,000/mm3. The nurse must monitor for bruising,
hematuria, and occult blood in the stool at this level.
5. A patient diagnosed with pernicious anemia asks why they must receive vitamin B12
injections rather than oral tablets. Which response by the nurse is correct?
A. The liver cannot process oral vitamin B12 in your condition.
B. Oral tablets are too expensive for long-term therapy.
C. The stomach is missing the intrinsic factor needed for absorption.
D. Injections work faster to cure the anemia permanently.
Correct Answer: C
