NCLEX Based MCQs #5
Q.41 The nurse cares for a client receiving a blood transfusion. The nurse notes that the client
has become hypotensive and febrile since the transfusion began. Which is the most appropriate
nursing action?
A. Stop the transfusion.
B. Notify the physician.
C. Decrease the rate of the transfusion.
D. Continue to monitor for signs and symptoms of a transfusion reaction.
Answer: A
✔✔ The client is experiencing symptoms of a transfusion reaction. In order to stop or limit the
reaction, the transfusion must be stopped. Then the physician should be notified to determine
the next course of action. Symptoms could become worse if the transfusion is continued
whether or not the rate is decreased.
Q.42 A client is to receive an intravenous injection of radiopaque dye for a diagnostic procedure.
The nurse knows which action is most important to take before administering the dye?
A. Obtaining baseline vital signs.
B. Obtaining height and weight.
C. Asking the client about allergies to iodine or shellfish.
D. None of these
Answer: C
✔✔ Although obtaining baseline vital signs and height and weight and reviewing intake and
Q.41 The nurse cares for a client receiving a blood transfusion. The nurse notes that the client
has become hypotensive and febrile since the transfusion began. Which is the most appropriate
nursing action?
A. Stop the transfusion.
B. Notify the physician.
C. Decrease the rate of the transfusion.
D. Continue to monitor for signs and symptoms of a transfusion reaction.
Answer: A
✔✔ The client is experiencing symptoms of a transfusion reaction. In order to stop or limit the
reaction, the transfusion must be stopped. Then the physician should be notified to determine
the next course of action. Symptoms could become worse if the transfusion is continued
whether or not the rate is decreased.
Q.42 A client is to receive an intravenous injection of radiopaque dye for a diagnostic procedure.
The nurse knows which action is most important to take before administering the dye?
A. Obtaining baseline vital signs.
B. Obtaining height and weight.
C. Asking the client about allergies to iodine or shellfish.
D. None of these
Answer: C
✔✔ Although obtaining baseline vital signs and height and weight and reviewing intake and
