A nurse is assisting with the care of a client who is receiving 1 unit of packed RBCs. The client is coughing and reports a headache and difficulty breathing. The client's vital signs indicate tachycardia and hypertension. The nurse should identify that the client is experiencing which of the following types of transfusion reactions?

Circulatory overload

Mild allergic

Febrile nonhemolytic

Sepsis

Answer and Explanation

The Correct Answer is A

A. Circulatory overload
Signs like cough, dyspnea, tachycardia, and hypertension are classic features of fluid overload due to rapid transfusion or volume excess.

B. Mild allergic
Presents with itching, hives, or flushing—not respiratory distress or hypertension.

C. Febrile nonhemolytic
Presents with fever, chills, and malaise, but not cough, headache, or hypertension.

D. Sepsis
Involves hypotension, fever, chills, and shock-like symptoms—not hypertension.

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Free Nursing Study Resources

Correct Answer is B

Explanation

A. Determining whether the client has incisional pain:
This requires assessment and clinical judgment, which is the nurse’s responsibility.

B. Transferring the client from the bed to a chair:
This is a task-based, routine activity that can safely be delegated to an assistive personnel.

C. Checking the client's surgical dressing for bleeding:
Assessing a wound for signs of bleeding is a nursing task.

D. Showing the client how to use an incentive spirometer:
Teaching is a nursing responsibility, not within the AP’s scope of practice.

A. Standing and bending forward at the waist B. Side-lying and drawing their knees up toward their chest C. Sitting with their arms out to their sides D. Lying in a prone position

Correct Answer is A

Explanation

A. Standing and bending forward at the waist
This position reveals spinal asymmetry, a hallmark of scoliosis.

B. Side-lying and drawing knees to chest
Used to relieve pain or examine the spine, but not standard for scoliosis screening.

C. Sitting with arms out
Does not allow clear visualization of spinal alignment.

D. Lying in a prone position
Ineffective for scoliosis screening because it flattens normal spinal curves.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is planning care for a client who is 1 day postoperative following abdominal surgery. Which of the following tasks should the nurse delegate to an assistive personnel?

Correct Answer is B

Explanation

A nurse is assisting a provider with a scoliosis screening for a school-age child. The nurse should assist the child into which of the following positions for the examination?

Correct Answer is A

Explanation

A nurse is caring for a client who is experiencing acute delirium and has slipped down in their bed. Which of the following actions should the nurse take when repositioning the client?

A nurse is collecting data from a client who has recently stopped smoking. Which of the following findings should the nurse recognize as a manifestation of acute nicotine withdrawal?

A nurse is reinforcing teaching about self-care with an adolescent client who has infectious mononucleosis with splenomegaly. Which of the following statements by the client indicates an understanding of the teaching?

A nurse on a mental health unit is discussing client rights with a client who is being admitted for treatment. Which of the following statements should the nurse include?

A nurse is assisting with the admission of a client to an acute-care unit following a suicide attempt. Which of the following actions should the nurse take first?

A nurse is caring for a client who has an early morning blood glucose level of 58 mg/dL. The client has a prescription for insulin aspart daily before breakfast. Which of the following actions should the nurse take first?

A nurse is preparing to give change-of-shift report to the oncoming nurse. Which of the following information should the nurse include?