The Category of Regret
A patient develops fever, chills, and a headache shortly after a transfusion. What is the most likely reaction, and what medication should the nurse anticipate giving?
What is Febrile Non-Hemolytic Reaction; and What is antipyretics (e.g., acetaminophen)
Why:
This is the most common reaction caused by cytokines; it’s uncomfortable but not life-threatening.
A patient receiving Total Parenteral Nutrition (TPN) suddenly has their infusion stopped. Name the nurse’s priority action to prevent hypoglycemia?
What is "Start an infusion of 10% dextrose (D10W)?
TPN has a high glucose concentration; stopping it abruptly causes a sharp insulin response → dangerous hypoglycemia.
A client with rheumatoid arthritis is on long-term immunosuppressive therapy: the main risk associated with this treatment.
What is increased risk of infection?
Immunosuppressants (like steroids, methotrexate) weaken the immune response, making it harder to fight infections.
A post-op orthopedic patient suddenly reports severe pain unrelieved by opioids — this is the priority nursing action.
What is perform a neurovascular assessment of the affected limb to assess for compartment syndrome?
Unrelieved pain may indicate compartment syndrome. You need a neurovascular check before notifying the provider.
If anemia is severe and prolonged, this late sign may occur due to inadequate oxygen reaching tissues, causing tissue damage.
What is ischemia?
A patient has the following labs: Hgb 7.4 g/dL, Hct 22%, BP 90/56, HR 112. This is the priority nursing intervention.
What is obtain a blood sample for type and crossmatch and prepare for possible PRBC transfusion?
Why:
These labs and vitals indicate symptomatic anemia with signs of hypovolemia. The patient will likely need a transfusion—getting type and crossmatch done early is key.
These two key nursing interventions will prevent aspiration when administering enteral tube feedings.
What is 1. Elevate the head of the bed to 30–45° and 2. Check tube placement before feeding or medication administration?
Why:
These steps reduce the risk of gastric contents entering the lungs—aspiration pneumonia is a major complication.
Which patient should the nurse see first.
A. A patient with Atrial Fibrillation
B. A patient with Sinus Tachycardia
C. A patient with Ventricle Tachycardia
D. A patient with Atrial Fibrillation
C. A patient with Ventricle Tachycardia
Name an early sign and a late sign of compartment syndrome.
What are severe pain (early sign) and pulselessness or paralysis (late signs)?
A patient with pernicious anemia cannot properly absorb this nutrient due to a deficiency of intrinsic factor.
What is B12?
A client with macrocytic anemia, tingling in hands and feet, glossitis, and balance issues is likely deficient in this nutrient.
❗What is Vitamin B12 (Pernicious Anemia)?
Why:
B12 is essential for RBC production and nerve function. Lack of intrinsic factor = poor absorption of Vitamin B 12.
A patient post-gastric bypass is experiencing dizziness, nausea, and diarrhea after eating. Name the syndrome is this, and one major dietary change that can help?
What is Dumping Syndrome; avoiding simple sugars/carbs?
Why:
Rapid gastric emptying causes these symptoms. A high-protein, low-carb diet and no fluids with meals helps slow digestion.
A client is admitted with an acute myocardial infarction (MI). Which nursing action is the highest priority during the first 12 hours after the MI?
A. Monitor intake and output every 4 hours
B. Assess lung sounds for crackles
C. Maintain continuous cardiac rhythm monitoring
D. Encourage early ambulation to prevent DVT
C. Maintain continuous cardiac rhythm monitoring
Rationale:
The first 12 hours after an MI carry the highest risk for life-threatening dysrhythmias, such as ventricular tachycardia and ventricular fibrillation. Continuous ECG monitoring allows for immediate detection and intervention. While the other actions are important, preventing fatal arrhythmias takes priority in the early post-MI period.
This is the priority nursing intervention when a patient with an amputation reports sharp, stabbing pain in the limb that is no longer there.
❗ Administer prescribed pain medications for phantom limb pain
Phantom pain is real and can be debilitating. Early and consistent pain management may reduce long-term pain and central sensitization.
The physician discovers a dialysis patient has low hemoglobin and anemia. The physician gives what IV medication.
What is Erythropoietin ?
A nurse is preparing to transfuse PRBCs. These four safety steps must be completed during the bedside verification process.
What is:
1. Use two patient identifiers 2.Check patient’s ID band against the blood bag 3. Verify patient and donor blood types 4. Crossmatch results must be confirmed with a second nurse?
Why:
Bedside verification prevents hemolytic transfusion reactions caused by mismatches.
Compare TPN and PPN by identifying: 1. One major route difference, 2. One difference in composition 3.One key difference when it comes to how long each can be used.
What is Route?: TPN uses a central line; PPN uses a peripheral IV
What is Composition?: TPN is more concentrated and contains lipids; PPN is less concentrated and may not contain fats
What is duration?: long term vs. short term. Use: TPN is for long-term support when the GI tract is non-functional; PPN is short-term or supplemental. WHY? TPN is hypertonic and can damage peripheral veins—requires central access for safe dilution and delivery.
A client is 24 hours post–myocardial infarction (MI). The nurse is monitoring for signs of heart failure. Which finding requires immediate follow-up?
A. Occasional premature ventricular contractions (PVCs)
B. New crackles in the lung bases
C. Mild chest discomfort relieved with rest
D. Heart rate of 98 beats/min
Correct Answer: B. New crackles in the lung bases
Rationale:
Heart failure is a common complication after an MI due to impaired contractility of the damaged myocardium. New or worsening crackles, dyspnea, orthopnea, or decreased oxygen saturation indicate left-sided heart failure and pulmonary congestion, requiring prompt intervention.
PVCs can occur after MI and are monitored but are not the most urgent finding.
Mild chest discomfort is common post-MI but not alarming if unchanged and relieved by rest.
HR 98 is within normal limits for a post-MI patient.
Name one key difference between Rheumatoid Arthritis (RA) and Osteoarthritis (OA) in each of the following:
Cause
Symptoms/affected joints
Lab values
Cause: RA is autoimmune; OA is from mechanical wear and tear. Joints/Symptoms: RA affects smaller joints symmetrically, with systemic inflammation; OA affects larger joints like knees and hips with bony overgrowth. Labs: RA shows elevated CRP/ESR; OA typically does not becasue RA = inflammation + immune-mediated and OA = physical degeneration
The low count of this type of cell prompts a nurse put her aplastic anemia patient on a pulse ox monitor.
What is RBCs?
Name one cause of a high RBC count and one cause of a low RBC count?
What is
High=↑ Polycythemia, dehydration
Low=↓ Anemia, hemorrhage?
Name one concern a major concern with TPN due to its route
What is Central Line Infection
A nurse is assessing a client with chronic right-sided heart failure. Which finding is most consistent with systemic venous congestion?
A. Fine crackles in the lung bases
B. Jugular venous distention
C. Fullness or discomfort in the left upper quadrant of the abdomen
D. Pink, frothy sputum
Correct Answer: C. Fullness or discomfort in the left upper quadrant of the abdomen
Rationale:
Right-sided heart failure causes blood to back up into the systemic circulation. This can lead to splenomegaly, which presents as left upper quadrant (LUQ) discomfort or fullness.
Other options point to:
A & D: Left-sided heart failure
B: A classic right-sided HF sign but not specific to abdominal organ congestion
Name two risks related to complete immobility following a tibia fracture.
What is increased risk for complications
Deep vein thrombosis (DVT) due to lack of movement
Pressure ulcers from prolonged pressure on bony prominences
Muscle atrophy and joint contractures
Decreased circulation and slow wound healing
This is the most likely cause of low blood pressure and hemodynamic instability in a post-surgical patient.
What is hypovolemia (due to bleeding or fluid loss)?