NUR1 NEWEST UPDATED 2025 REAL FINAL EXAM WITH
COMPLETE DETAILED QUESTIONS AND CORRECT VERIFIED
ANSWERS ALREADY A+ GRADED
A client in sickle cell crisis has been hospitalized during her pregnancy.
After giving discharge instructions, the nurse determines the client
needs further teaching when she makes which statement?
a) "Signs of any type of infection must be reported immediately."
b) "At the earliest signs of a crisis, I need to seek treatment."
c) "I will need more frequent appointments during the remainder of the
pregnancy."
d) "I will need to take an iron supplement even if my laboratory values
are normal."
ANSWER-"I will need to take an iron supplement even if my laboratory
values are normal."
Sickle cell disease is an autosomal recessive disorder requiring both
parents to have a sickle cell trait to pass the disease to a child.
Deoxygenated hemoglobin cells assume a sickle shape and obstruct
tissues. Tissue obstruction causes hypoxia to the area (vaso-occlusion)
and results in pain, called sickle cell crisis. This type of anemia is an
,inherited disorder; it is not caused by lack of iron in the diet. Iron
supplementation is needed only if there is laboratory evidence of iron
deficiency anemia. Self-monitoring for any type of infections or sickle
cell crisis and increased frequency of antenatal care visits are part of
the teaching plan of care.
A client is receiving a unit of packed red blood cells. Before the
transfusion started, the client's blood pressure was 90/50 mm Hg, pulse
rate 100 bpm, respirations 20 breaths/minute, and temperature 98° F
(36.7° C). Fifteen minutes after the transfusion starts, the client's blood
pressure is 92/54 mm Hg, pulse 100 bpm, respirations 18
breaths/minute, and temperature is 101.4° F (38.6° C). The nurse
should first:
a) obtain a prescription for antibiotics.
b) stop the transfusion.
c) raise the head of the bed.
d) offer the client a cool washcloth.
ANSWER-stop the transfusion.
The nurse's first action should be to clamp off the transfusion because
the client is having a transfusion reaction. It is most important that the
client not receive any more blood. Other measures may be appropriate
after the blood has been stopped. The nurse should raise the head of
,the bed if the client becomes short of breath. There is no need for
antibiotic therapy for a blood transfusion related to a temperature
spike. The nurse can provide a cool washcloth for a headache or fever;
however, this is not a priority.
A client receiving a blood transfusion experiences an acute hemolytic
reaction. Which nursing intervention is the most important?
a) Stop the transfusion, notify the blood bank, and administer
antihistamines.
b) Assess the temperature, blood pressure, and check for blood in the
urine. Then stop the transfusion.
c) Slow the transfusion and monitor the client's vital signs.
d) Stop the transfusion, infuse normal saline solution, and call the
physician.
ANSWER-Stop the transfusion, infuse normal saline solution, and call
the physician.
When a transfusion reaction occurs, the transfusion should be
immediately stopped, normal saline solution should be infused to
maintain venous access, and the physician and blood bank should be
notified immediately. Other nursing actions include saving the blood
bag and tubing, rechecking the blood type and identification numbers
on the blood tags, monitoring vital signs, obtaining necessary
laboratory blood and urine samples, providing proper documentation,
, and monitoring and treating for shock. Because they can cause red
blood cell hemolysis, dextrose solutions should not be infused with
blood products. Antihistamines are administered for a mild allergic
reaction, not a hemolytic reaction
A client with pernicious anemia asks why she must take vitamin B12
injections forever. Which is the nurse's best response?
a) "The reason for your vitamin deficiency is an inability to absorb the
vitamin because the stomach is not producing sufficient amounts of a
factor that allows the vitamin to be absorbed."
b) "The reason for your vitamin deficiency is an inability to absorb the
vitamin because the stomach is not producing sufficient acid."
c) "The reason for your vitamin deficiency is an increased requirement
for the vitamin because of rapid red blood cell production."
d) "The reason for your vitamin deficiency is an excessive excretion of
the vitamin because of kidney dysfunction."
ANSWER-The reason for your vitamin deficiency is an inability to absorb
the vitamin because the stomach is not producing sufficient amounts of
a factor that allows the vitamin to be absorbed."
Most clients with pernicious anemia have deficient production of
intrinsic factor in the stomach. Intrinsic factor attaches to the vitamin in
the stomach and forms a complex that allows the vitamin to be
absorbed in the small intestine. The stomach is producing enough acid,
COMPLETE DETAILED QUESTIONS AND CORRECT VERIFIED
ANSWERS ALREADY A+ GRADED
A client in sickle cell crisis has been hospitalized during her pregnancy.
After giving discharge instructions, the nurse determines the client
needs further teaching when she makes which statement?
a) "Signs of any type of infection must be reported immediately."
b) "At the earliest signs of a crisis, I need to seek treatment."
c) "I will need more frequent appointments during the remainder of the
pregnancy."
d) "I will need to take an iron supplement even if my laboratory values
are normal."
ANSWER-"I will need to take an iron supplement even if my laboratory
values are normal."
Sickle cell disease is an autosomal recessive disorder requiring both
parents to have a sickle cell trait to pass the disease to a child.
Deoxygenated hemoglobin cells assume a sickle shape and obstruct
tissues. Tissue obstruction causes hypoxia to the area (vaso-occlusion)
and results in pain, called sickle cell crisis. This type of anemia is an
,inherited disorder; it is not caused by lack of iron in the diet. Iron
supplementation is needed only if there is laboratory evidence of iron
deficiency anemia. Self-monitoring for any type of infections or sickle
cell crisis and increased frequency of antenatal care visits are part of
the teaching plan of care.
A client is receiving a unit of packed red blood cells. Before the
transfusion started, the client's blood pressure was 90/50 mm Hg, pulse
rate 100 bpm, respirations 20 breaths/minute, and temperature 98° F
(36.7° C). Fifteen minutes after the transfusion starts, the client's blood
pressure is 92/54 mm Hg, pulse 100 bpm, respirations 18
breaths/minute, and temperature is 101.4° F (38.6° C). The nurse
should first:
a) obtain a prescription for antibiotics.
b) stop the transfusion.
c) raise the head of the bed.
d) offer the client a cool washcloth.
ANSWER-stop the transfusion.
The nurse's first action should be to clamp off the transfusion because
the client is having a transfusion reaction. It is most important that the
client not receive any more blood. Other measures may be appropriate
after the blood has been stopped. The nurse should raise the head of
,the bed if the client becomes short of breath. There is no need for
antibiotic therapy for a blood transfusion related to a temperature
spike. The nurse can provide a cool washcloth for a headache or fever;
however, this is not a priority.
A client receiving a blood transfusion experiences an acute hemolytic
reaction. Which nursing intervention is the most important?
a) Stop the transfusion, notify the blood bank, and administer
antihistamines.
b) Assess the temperature, blood pressure, and check for blood in the
urine. Then stop the transfusion.
c) Slow the transfusion and monitor the client's vital signs.
d) Stop the transfusion, infuse normal saline solution, and call the
physician.
ANSWER-Stop the transfusion, infuse normal saline solution, and call
the physician.
When a transfusion reaction occurs, the transfusion should be
immediately stopped, normal saline solution should be infused to
maintain venous access, and the physician and blood bank should be
notified immediately. Other nursing actions include saving the blood
bag and tubing, rechecking the blood type and identification numbers
on the blood tags, monitoring vital signs, obtaining necessary
laboratory blood and urine samples, providing proper documentation,
, and monitoring and treating for shock. Because they can cause red
blood cell hemolysis, dextrose solutions should not be infused with
blood products. Antihistamines are administered for a mild allergic
reaction, not a hemolytic reaction
A client with pernicious anemia asks why she must take vitamin B12
injections forever. Which is the nurse's best response?
a) "The reason for your vitamin deficiency is an inability to absorb the
vitamin because the stomach is not producing sufficient amounts of a
factor that allows the vitamin to be absorbed."
b) "The reason for your vitamin deficiency is an inability to absorb the
vitamin because the stomach is not producing sufficient acid."
c) "The reason for your vitamin deficiency is an increased requirement
for the vitamin because of rapid red blood cell production."
d) "The reason for your vitamin deficiency is an excessive excretion of
the vitamin because of kidney dysfunction."
ANSWER-The reason for your vitamin deficiency is an inability to absorb
the vitamin because the stomach is not producing sufficient amounts of
a factor that allows the vitamin to be absorbed."
Most clients with pernicious anemia have deficient production of
intrinsic factor in the stomach. Intrinsic factor attaches to the vitamin in
the stomach and forms a complex that allows the vitamin to be
absorbed in the small intestine. The stomach is producing enough acid,
