Nclex Case Study Nursing

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NCLEX Questions
The following two alternate format NCLEX questions were created related to the case study information and focus on the nursing responsibilities prior to blood administration and the signs/symptoms of acute hemolytic transfusion reactions.
NCLEX Question #1
The RN on day shift is looking after Anita, a 93-year-old female patient in with an upper GI bleed. Anita’s latest lab results show an Hgb of 62 g/L. The registered nurse notifies the physician, who then orders for Anita to receive 1 unit of packed red blood cells (PRBCs). What are some of the nursing responsibilities before administering the ordered PRBCs? Select all that apply:
A. Check the transfusion order and verify that consent was obtained
B. Check compatibility
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Therefore, Lactated Ringers is not an appropriate IV solution selection in this scenario.
• F is incorrect because while patients over 70-years old are at risk for fluid overload, the nurse would assess the patient’s lungs, however assessment of the heart is not necessary. Moreover, the RN should measure vital signs and assess lung sounds before the transfusion, after the first 15 minutes and every 30 minutes to 1 hour, per agency policy, until 1 hour after the transfusion is completed (Silvestri, 2018).
NCLEX Question #2
A nursing instructor is teaching a class of nursing students about acute hemolytic transfusion reactions. Which of the following statements regarding indications of an acute hemolytic transfusion reaction made by the student nurse would indicate the need for further education. Select all that apply:
1. Chills, fever, low back pain, bradycardia and dyspnea
2. Reaction developed within 15 minutes of transfusion
3. Chills, fever, low back pain, tachycardia and
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Hypotension, flushing and hemoglobinuria
5. Reaction developed 30 hours after the transfusion
6. Hypertension, flushing and hemoglobinuria
Rational for Answers to NCLEX Question #2
Correct Answers The question is asking about the need for further education, meaning the student provided the wrong answers; therefore, the correct answers are as follows:
• 1. Braydcardia is incorrect, as the patient would present with tachycardia (Menendez & Edwards, 2016).
• 5. Reactions past 24-hours would not be considered acute and are not characteristic for acute hemolytic transfusion reactions (Silvestri, 2018). Typically the client would react within the first 15 minutes or within 24-hours to be considered acute (Silvestri, 2018).
• 6. Hypertension is incorrect, as the patient would present with hypotension (Callum et al., 2016).
Incorrect Answers
While these are the accurate signs and symptoms of an acute hemolytic transfusion reaction, the question is asking for need for further education; therefore, the incorrect answers are as follows:
• 2. Acute hemolytic reactions usually occur within the first 15 minutes of the transfusion, but can be recognized in the 24-hour period to be considered acute (Silvestri,

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