A. Allergic – An allergic reaction typically presents with itching, rash, and wheezing rather than fever, chills, and hematuria.

B. Hemolytic – Correct Answer. A hemolytic reaction occurs when the immune system attacks transfused red blood cells due to incompatibility. Symptoms include fever, chills, hypotension, back pain, and hematuria (red-tinged urine). This is a medical emergency requiring immediate intervention.

C. Acute pain – Acute pain transfusion reaction is rare and mainly presents with severe chest, back, and joint pain, without fever or hematuria.

D. Febrile – Febrile reactions cause fever and chills but do not typically cause hematuria, which is indicative of hemolysis.

A. Platelets 110,000 mm³ – Correct Answer. A low platelet count (thrombocytopenia) increases the risk of bruising and bleeding. Normal platelet range is 150,000–400,000 mm³.

B. WBC 8,000 mm³ – Normal white blood cell count; does not explain increased bruising.

C. Hemoglobin 13.0 g/dL – Normal hemoglobin level; not related to bruising.

D. RBC 4.6 million/mm³ – Normal RBC count; does not indicate a bleeding risk.

A. Encourage the patient to ask for assistance. – Patients with Alzheimer's often forget to ask for help, making this an unreliable safety measure.

B. Keep the call light near the patient. – The patient may not remember to use the call light.

C. Place the patient in a room close to the nurses' station. – Correct Answer. This allows frequent observation and quick intervention to prevent falls.

D. Remind the patient to walk with someone for support. – Reminders may not be effective due to memory impairment.

A. Suggest the visitors stay a bit longer to provide support and distraction. – Noise and stimulation can worsen migraines.

B. Suggest the patient ambulates in the hallway to become fatigued, so they can rest. – Movement may increase pain.

C. Turn the lights and television off except for a night light. – Correct Answer. Migraines are worsened by light and noise, so a dark and quiet environment is best.

D. Turn on the television to be used as a distractor for the patient. – Bright lights and sound can aggravate symptoms.

A. Neutropenic – Used for low WBC count, not platelets.

B. Contact – Used for infections like C. diff or MRSA.

C. Droplet – Used for respiratory illnesses like flu or meningitis.

D. Bleeding – Correct Answer. A low platelet count increases the risk of bleeding, so bleeding precautions are necessary (e.g., soft toothbrush, avoiding IM injections, fall precautions).

A. Chart – Contains patient information but is not used for immediate verification before transfusion.

B. Order sheet – Ensures the transfusion is ordered but does not confirm patient identity.

C. Medication administration record – Lists medications but is not used to verify transfusion identity.

D. Identification wristband – Correct Answer. The wristband is the most accurate and immediate source for patient verification before administering blood products.

A. Give potassium intravenously. – The potassium level is 3.7 (within normal range 3.5–5.0), so potassium is not needed yet.

B. Administer D5 NS with the insulin drip. – Correct Answer. Once glucose drops to ≤200 mg/dL, dextrose is added to prevent hypoglycemia while continuing insulin to correct ketoacidosis.

C. Administer 3% NS at 200 mL/hr. – Hypertonic saline is used for severe hyponatremia, which is not the case here.

D. Expect the insulin drip to be discontinued. – The insulin drip is not discontinued until ketoacidosis has fully resolved (when HCO3 > 18, pH > 7.3, and anion gap normalizes).

A. Incorrect → Insulin injections should be administered at a 90-degree angle unless the patient has minimal subcutaneous fat, in which case a 45-degree angle is used. A 25-degree angle is too shallow and may lead to improper absorption.

B. Rotating insulin injection sites helps prevent lipodystrophy and ensures consistent absorption. The patient’s decision to inject in the thigh after using the abdomen in the morning demonstrates proper site rotation.

C. Incorrect → Insulin should be administered with a U-100 insulin syringe (not a 1 mL syringe) to ensure accurate dosing.

D. Incorrect → While injecting an inch away from a previous site is reasonable, the preferred practice is rotating between different anatomical sites to prevent tissue damage and inconsistent absorption.

A. Incorrect → Weight gain (even if minor) can indicate poor glucose control, especially if linked to fluid retention or insulin resistance.

B. Regular ophthalmology exams are crucial for early detection of diabetic retinopathy, a leading cause of blindness in diabetes. Scheduling an eye appointment demonstrates proactive disease management.

C. Incorrect → A Hemoglobin A1c of 8.1% is above the target range (typically <7% for diabetics) and indicates poor blood glucose control over the past 2-3 months.

D. Incorrect → A reddened area on the sole of the foot suggests early signs of diabetic foot complications and possible neuropathy or poor circulation, requiring intervention.

A. Inserting an indwelling urinary catheter – Incorrect. While catheterization may be necessary, it is not the highest priority for an unconscious patient.

B. Putting a nasogastric (NG) tube in place – Incorrect. NG tube placement can be useful for feeding or decompressing the stomach, but airway management takes precedence.

C. Maintaining a patent airway – Correct Answer. Airway patency is the top priority in an unconscious patient to prevent aspiration, hypoxia, or respiratory failure.

D. Administering an enema daily – Incorrect. This is not a priority in unconscious patients.