C. Delay Hanging The Blood and Notify The HCP

1. Packed red blood cells have been prescribed for a client with low hemoglobin and hematocrit levels.
The nurse takes

the client's temperature before hanging the blood transfusion and records 100.6 orally, which action should the nurse
take?
a. Begin the transfusion as prescribed

b. Administer an antihistamine and begin the transfusion
c. Delay hanging the blood and notify the HCP
d. Administer two tablets of Tylenol and begin the transfusion
RATIONALE: C. If the client has a temperature higher than 100 degrees F the unit of blood should not be hung until the
HCP is notified and has the opportunity to give further prescriptions. The HCP likely will prescribe that the blood be
administered regardless of the temperature, but the decision is not within the nurse's scope of practice to make. The
nurse needs an HCP's prescription to administer medications to the client.
2. The nurse has received a prescription to transfuse a client with a unit of packed red blood cels. Before explaining the
procedure to the client, the nurse should ask which initial question?
a. "Have you ever had a transfusion before?"

b. "Why do you think that you need the transfusion?"
c. "Have you ever gone into shock for any reason in the past?"
d. "Do you know the complications and risks of a transfusion?"
RATIONALE: A. Asking a client about personal experience with transfusion therapy provides a good starting point for
client teaching about this procedure. Questioning about previous history of shock and knowledge of complications and
risks of transfusion are not helpful because they may elicit a fearful response from the client. Although determining
whether the client knows the reason for the transfusion is important, it is not an appropriate statement in terms of
eliciting information from the client regarding an understanding of the need for the transfusion.
3. A client receiving a transfusion of packed red blood cells begins to vomit. The clients blood pressure is 90/50mm Hg
from a baseline of 125/78 mmHg. The client's temperature is 100.8 degrees F orally from a baseline of 99.2 degrees F
orally. The nurse determines that the client may be experiencing which complication of a blood transfusion?
a. Septicemia
b. Hyperkalemia
c. Circulatory overload
d. Delayed transfusion reaction
RATIONALE: A. Septicemia occurs with the transfusion of blood contaminated with microorganisms. Signs include chills,
fever, vomiting, diarrhea, hypotension, and the development of shock; Hyperkalemia causes weakness, paresthesias,
abdominal cramps, diarrhea, and dysrhythmias; Circulatory overload causes cough, dyspnea, chest pain, wheezing,
tachycardia, and hypertension; A delayed transfusion reaction can occur days to years after a transfusion. Signs include
fever, mild jaundice, and a decreased hematocrit level.
4. The nurse determines that a client is having a transfusion reaction. After the nurse stops the transfusion, which action
should be taken next?
a. Remove the IV line

b. Run a solution of 5% dextrose in water
c. Run normal saline at a keep vein open rate
d. Obtain a culture of the tip of the catheter device removed from the client
RATIONALE: C. If the nurse suspects a transfusion reaction, the nurse stops the transfusion and infused normal saline at
a keep vein open rate pending further HCP prescriptions. This maintains a patent IV access line and aids in maintaining
the client's intravascular volume; The nurse would NOT remove the IV line because then there would be no IV access
route; Obtaining a culture of the tip of the catheter device removed from the client is incorrect. First, the catheter
should NOT be removed. Second, cultures are performed when infection, NOT transfusion reactions, is suspected;
Normal saline is the solution of choice over solutions containing dextrose because saline does not cause red blood cells
to clump.
5. The nurse has just received a unit of packed red blood cells from the blood bank for transfusion to an assigned client.
The nurse is careful to select tubing especially made for blood products, knowing that his tubing is manufactured with
which item?
a. An air vent
b. Tinted tubing
c. An inline filter
d. A Microdrip chamber
RATIONALE: C. The tubing used for blood administration has an in line filter. The filter helps ensure that any particles
larger than the size of the filter are caught in the filter and are not infused into the client.
6. A client has received a transfusion of platelets. The nurse evaluates that the client is benefiting most from this therapy
if the client exhibits which finding?
a. Increased hematocrit level

b. Increased hemoglobin level
c. Decline of elevated temperature to normal
d. Decreased oozing of blood from puncture sites and gums
RATIONALE: D. Platelets are necessary for proper blood clotting. The client with insufficient platelets may exhibit frank
bleeding or oozing of blood from puncture sites, wounds, and mucous membranes.
7. The nurse has obtained a unit of blood from the blood bank and has checked the blood bag properly with another nurse.
Just before beginning the transfusion, the nurse should assess which priority item?
a. Vital signs
b. Skin color
c. Urine output
d. Latest hematocrit level
RATIONALE: A. A change in the vital signs during the transfusion from baseline may indicate that a transfusion reaction
is occurring.
8. The nurse has just received a prescription to transfuse a unit of packed red blood cells for an assigned client.
Approximately how long will the nurse need to stay with the client to ensure that a transfusion reaction is not occurring?
a. 5 mins
b. 15 mins
c. 30 mins
d. 45 mins
RATIONALE: B. The first 15 mins is usually when a transaction reaction would occur
9. Following infusion of a unit of packed red blood cells, the client has developed new onset of tachycardia, bounding
pulses, crackles, and wheezes. Which action should the nurse implement first?
a. Maintain bed rest with legs elevated

b. Place the client in high-fowlers position
c. Increase the rate of infusion of intravenous fluids
d. Consult with the HCP regarding initiation of O2 therapy
RATIONALE: B. These symptoms are evidence of circulatory overload. Placing the client in high fowlers will facilitate
breathing. Measures that increase blood return o the heart, such as leg elevation and administration of IV fluids, should
be avoided at this time.
10. The nurse, listening to the morning report, learns that an assigned client received a unit of granulocytes the previous
evening. The nurse makes a note to assess the results of which daily serum lab studies to assess the effectiveness of the
transfusion?
a. Hematocrit level
b. Erythrocyte count
c. Hemoglobin level
d. White blood cell count
RATIONALE: D. The client who has neutropenia may receive a transfusion of granulocytes, or white blood cells. These
clients often have severe infections and are unresponsive o antibiotic therapy. The nurse notes the results of follow up
white blood cell counts and differential to evaluate the effectiveness of therapy.
11. A client is brought to the ED having experienced blood loss related to an arterial laceration. Fresh-frozen plasma is
prescribed and transfused to replace fluid and blood loss. The nurse understands that which is the rationale for transfusing
fresh-frozen plasma to this client?
a. To treat the loss of platelets

b. To promote rapid volume expansion
c. Because a transfusion must be done slowly
d. Because it will increase the hemoglobin and hematocrit levels
RATIONALE: B. Fresh frozen plasma is often used for volume expansion as a result of fluid and blood loss. It does not
contain platelets, so it is not used to treat any type of low platelet count disorder. It is rich in clotting factors and can be
thawed quickly and transfused quickly.
12. The nurse who is about to begin a blood transfusion knows that blood cells start to deteriorate after a certain period
of time. Which item is important to check regarding the age of blood cells before the transfusion is begun?
a. Expiration date
b. Presence of clots
c. Blood group and type
d. Blood identification number
RATIONALE: A. The nurse notes the expiration date on the unit of blood to ensure the blood is fresh. Blood cells begin to
deteriorate over time, so safe storage usually is limited to 35 days. The nurse also notes the blood identification number,
blood group and type and client's name.
13. A client requiring surgery is anxious about the possible need for a blood transfusion before or after the procedure. The
nurse suggests to the client to take which action to reduce the risk of possible transfusion complications? Select all that
apply
a. Ask a family member to donate blood ahead of time

b. Give an autologous blood donation before the surgery
c. Take iron supplements before surgery to boost hemoglobin levels
d. Request that any donated blood be screened twice by the blood bank
e. Take adequate amounts of vitamin C several days prior to the surgery date
RATIONALE: A and B. A donation of the client's own blood before a scheduled procedure is autologous. The next most
effective way is to ask a family member to donate blood before surgery.
14. A client with severe blood loss resulting from multiple trauma requires rapid transfusion of several units of blood. The
nurse asks another health team member to obtain which device for use during the transfusion procedure to help reduce
the risk of cardiac dysrhythmias?
a. Infusion pump
b. Pulse oximeter
c. Cardiac monitor
d. Blood-warming device
RATIONALE: D. If several units of blood are to be administered, a blood warmer should be used. Rapid transfusion of
cool blood places the client at risk for cardiac dysrhythmias.
15. A client has a prescription to receive a unit of packed red blood cells. The nurse should obtain which IV solution from
the storage area to hang with the blood products at the client's bedside?
a. Lactated ringers
b. 0.9% sodium chloride
c. 5% dextrose in 0.9% sodium chloride
d. 5% dextrose in 0.45% sodium chloride
RATIONALE: B. Sodium chloride 0.9% is a standard isotonic solution used to precede and follow infusion of blood
products. Dextrose is not used because it could result in clumping and subsequent hemolysis of red blood cells.
1. The nurse has obtained a unit of blood from the blood bank and has checked the blood bag properly with another nurse.
Just before beginning the transfusion, the nurse assesses which priority item?
a. Vital signs
b. Skin color
c. Urine output
d. D. Latest hematocrit level
RATIONALE: A. vital signs - A change in VS during the transfusion from baseline may indicate that a transfusion reaction
is occurring. This is why the nurse assesses vital signs before the procedure and again after the first 15 minutes.
2. The nurse has discontinued a unit of blood that was infusing into a client because the client experienced a transfusion
reaction. After documenting the incident appropriately, the nurse sends the blood bag and tubing to which of the following
departments?
a. Blood bank
b. Risk management
c. Environmental services
d. Infection control
RATIONALE: A. blood bank - The nurse returns the blood transfusion bag containing any remaining blood to the blood
bank. This allows the blood bank to complete any follow-up testing procedures needed once a transfusion reaction has
been documented. The other option identify incorrect departments.
3. Packed red blood cells have been prescribed for a client with low hemoglobin and hematocrit levels. The nurse takes
the client's temperature before hanging the blood transfusion and records 100.6F orally. Which of the following is the
appropriate nursing action?
a. Begin the transfusion as prescribed

b. Delay hanging the blood and notify the physician
c. Administer an antihistamine and begin the transfusion
d. Administer two tablets of acetaminophen (Tylenol) and begin the transfusion
RATIONALE: b. Delay hanging the blood and notify the physician - If the client's temperature is higher than 100F the unit
of blood should not be hung until the physician is notified and has the opportunity to give further prescriptions. The
physician will likely prescribe that the blood be administered regardless of the temperature, but the decision is not
within the nurse's scope of practice to make.
4. A nurse is preparing medication for administration. In addition to the right medication, the nurse adheres to which of
the following additional rights of medication administration. Select all that apply.
a. The right route

b. The right staff member
c. The right time
d. The right client
e. The right documentation
f. The right dose
RATIONALE: A, C, D, E, F - There are six rights to administering medications: The right medication, the right client, the
right dose, the right route, the right time, and the right documentation.
5. A client is brought to the emergency department having experienced blood loss related to an arterial laceration. Fresh-
frozen plasma is prescribed and transfused to replace fluid and blood loss. The nurse understands that the rationale for
transfusing fresh-frozen plasma in this client is:
a. to treat the loss of platelets

b. to promote rapid volume expansion
c. That the transfusion must be done slowly
d. That it will increase the hemoglobin and hematocrit levels.
RATIONALE: B. to promote rapid volume expansion - Fresh-frozen plasma is often used for volume expansion as a result
of fluid and blood loss. It does not contain platelets, so it is not used to treat any type of low platelet count disorder. It is
rich in clotting factors and can be thawed quickly and transfused quickly. It will not specifically increase the hemoglobin
and hematocrit level.
6. A client receiving a transfusion of packed red blood cells (PRBCs) begins to vomit. The client's blood pressure is 90/50
from a baseline of 125/78. The client's temperature is 100.8F orally from a baseline of 99.2F orally. The nurse determines
that the client may be experiencing which complication of a blood transfusion?
a. Septicemia
b. Hyperkalemia
c. Circulatory overload
d. Delayed transfusion reaction
RATIONALE: A. Septicemia - Septicemia occurs with the transfusion of blood contaminated with microorganisms. Signs
include chills, fever, vomiting, diarrhea, hypotension, and the development of shock. Hyperkalemia causes weakness,
paresthesias, abdominal cramps, diarrhea, and dysrythmias. Circulatory overload causes cough, dyspnea, chest pain,
wheezing, tachycardia, and hypertension. A delayed transfusion reaction can occur days or weeks after a tranfusion.
Signs include fever, mild jaundice, and a decreased hematocrit level.
7. The nurse has received a prescription to transfuse a client with a unit of packed red blood cells. Before explaining the
procedure to the client, the nurse asks which initial question?
a. "have you ever had a transfusion before?"

b. "why do you think that you need the transfusion?"
c. "have you ever gone into shock for any reason in the past?"
d. "do you know the complications and risks of a transfusion?"
RATIONALE: a. "have you ever had a transfusion before?" - Asking the client about personal experience with transfusion
therapy provides a good starting point for client teaching about this procedure. Options C and E are not helpful because
they may elicit a fearful response from the client. Although determining whether the client knows the reason for the
transfusion is important, option B is not an appropriate statement in terms of eliciting information from the client
regarding an understanding of the need for the transfusion
8. A client has received a transfusion of platelets. The nurse evaluates that the client is benefiting most from this therapy
if the client exhibits which of the following?
a. Increased hematocrit level

b. Increased hemoglobin level
c. Decline of elevated temperature to normal
d. Decreased oozing of blood from puncture sites and gums
RATIONALE: d. Decreased oozing of blood from puncture sites and gums - Platelets are necessary for proper blood
clotting. The client with insufficient platelets may exhibit frank bleeding or oozing of blood from puncture sites, wounds,
and mucous membranes. Increased hemoglobin and hematocrit levels would occur when the client has received a
transfusion of red blood cells. An elevated temperature would decline to normal after infusion of granulocytes if those
cells were instrumental in fighting infection in the body.
9. The nurse is picking up a unit of packed red blood cells at the hospital blood bank. After putting the pen down, the nurse
glances at the clock, which reads 1:00. The nurse calculates that the transfusion must be started by:
a. 1:30
b. 2:00
c. 2:30
d. 3:00
RATIONALE: a. 1:30 - Blood must be hung as soon as possible within 30 mintues after it is obtained from the blood bank.
10. A client has experienced a rash with pruritus during previous blood transfusions. The client asks the nurse whether it
is safe to receive another transfusion. In formulating a response, the nurse incorporates the understanding that which
medication will most likely be prescribed before the transfusion is begun?
a. Ibuprofen (Motrin)
b. Acetaminophen (Tylenol)
c. Diphenhydramine (Benadryl)
d. Acetylsalicylic Acid (ASA Aspirin)
RATIONALE: C. Diphenhydramine (Benadryl) - An urticarial reaction is characterized by a rash accompanied by pruritus.

This type of transfusion reaction is prevented by pretreating the client with an antihistamine such as diphenhydramine.
Acetaminophen and ASA are analgesics and ibuprofen is a NSAID
11. A client has a prescription to receive a unit of packed red blood cells. The nurse should obtain which of the following
IV solutions form the IV storage area to hang with the blood product at the client's bedside?
a. Lactated Ringer's
b. 0.9% sodium chloride
c. 5% dextrose in 0.9% sodium chloride
d. 5% dextrose in 0.45% sodium chloride
RATIONALE: B. 0.9% sodium chloride - Sodium chloride 0.9% (normal saline) is a standard isotonic solution used to
precede and follow infusion of blood products. Dextrose is not used because it could result in clumping and subsequent
hemolysis of red blood cells. Lactated ringer's is not the solution of choice with this procedure.
12. A nurse has an order to transfuse a unit of packed red blood cells to a client who does not currently have an IV line
inserted. When obtaining supplies to start the IV infusion the nurse selects an angiocatheter with a size of:
a. 18 gauge
b. 21 gauge
c. 22 gauge
d. 24 gauge
RATIONALE: A. 18 gauge - The IV catheter used for a blood transfusion should be at least 18 or 19 gauge. Compared with
IV solutions, blood has a thicker and stickier consistency, and use of an 18 or 19 gauge catheter will ensure that the bore
of the catheter is large enough to prevent damage to the blood cells.
13. A client requiring surgery is anxious about the possible need for a blood transfusion during or after the procedure.
The nurse suggests to the client to do which of the following to reduce the risk of possible transfusion complications?
a. give an autologous blood donation before the surgery

b. ask a friend or family member to donate blood ahead of time
c. take iron supplements before surgery to boost hemoglobin levels
d. request that any donated blood be screened twice by the blood bank.
RATIONALE: a. give an autologous blood donation before the surgery - A donation of the client's own blood before a
scheduled procedure is autologous. Donating autologous blood to be reinfused as needed during or after surgery
reduces the risk of disease transmission and potential transfusion complications. The next most effective way is ask a
family member to donate blood before surgery. Blood banks do not provide extra screening on request. Preoperative
iron supplements are not helpful in replacing blood lost during the surgery.
1. Which nursing intervention takes highest priority when caring for a newly admitted client who’s receiving a blood
transfusion?
a. Warming the blood prior transfusion.

b. Informing the client that the transfusion usually takes 4 to 6 hours.
c. Documenting blood administration in the client chart.
d. Instructing the client to report any itching, chest pain, or dyspnea.
RATIONALE: D. Instructing the client to report any itching, headache, or dyspnea. This will help the nurse take
immediate action incase a reaction happens during a transfusion.
2. Nurse Paulo has received a blood unit from the blood bank and has rechecked the blood bag properly with nurse
Edward. Prior the facilitation of the blood transfusion, nurse Paulo priority check which of the following?
a. Intake and output.

b. NPO standing order.
c. Vital signs.
d. Skin turgor.
RATIONALE: C. Vital signs. The nurse must assess the vital signs before and 15 minutes after the procedure so that any
changes during the transfusion may indicate a transfusion reaction is happening.
3. A client is brought to the emergency department having experienced blood loss due to a deep puncture wound. A 3
unit Fresh-frozen plasma (FFP) is ordered. The nurse determines that the reason behind this order is to:
a. Provide clotting factors and volume expansion.

b. Increase hemoglobin, hematocrit, and neutrophil levels.
c. Treat platelet dysfunction.
d. Treat thrombocytopenia.
RATIONALE: A. Provide clotting factors and volume expansion. Fresh-frozen plasma may be used to provide clotting
factors or volume expansion. It is rich in clotting factors and can be thawed quickly and transfused right away; Option B
is incorrect since it will not specifically increase the hemoglobin, hematocrit, and neutrophil level; Options C and D are
incorrect since FFP does not contain any platelet.
4. Nurse Amanda is caring for a client with severe blood loss who is prescribed with multiple transfusion of blood. Nurse
Amanda obtains which most essential piece of equipment to prevent the risk of cardiac dysrhythmias?
a. Cardiac monitor.
b. Blood warmer.
c. ECG machine.
d. Infusion pump.
RATIONALE: Answer: B. Blood warmer. Rapid transfusion of cool blood put the client at risk for cardiac dysrhythmias;
Options A and C are used to assess for any blood transfusion-related complication, but they do not prevent the
occurrence of cardiac dysrhythmia; Option D is not beneficial in this case since the infusion must be given rapidly.
5. A client is receiving a first-time blood transfusion of packed RBC. How long should the nurse stay and monitor the
client to ensure a transfusion reaction will not happen?
a. 15 minutes.
b. 30 minutes.
c. 45 minutes.
d. 60 minutes.
RATIONALE: A. 15 minutes. Usually, a transfusion reaction occurs within the 15 minutes of a transfusion.
6. Nurse Rick is administering a 2 unit packed RBC’s on a client with a low hemoglobin. The nurse will prepare which of
the following in order to transfuse the blood?
a. Microfusion set.
b. Polyvol Pro Burette Set.
c. Photofusion set.
d. Tubing with an in-line filter.
RATIONALE: D. Tubing with an in-line filter. The in-line filter helps ensure that any particles larger than the size of the
filter are caught in the filter and are not infused with the client; Option A is incorrect since the tubing that should be
used is a macro drip; Option B is used for administration of IV medication infusion; Option C is incorrect since blood does
not need any protection from light.
7. To verify the age of blood cells in a blood, the nurse will check which of the following?
a. Blood type.
b. Blood group.
c. Blood identification number.
d. Blood expiration date.
RATIONALE: D. Blood expiration date. The safe storage of blood usually takes 35 days. Examining the expiration date is
an important responsibility of a nurse prior hanging the blood.
8. A client has an order to receive a one unit of packed RBC’s. The nurse make sure which of the following intravenous
solutions to hang with the blood product at the client’s bedside?
a. 0.9% sodium chloride.
b. 5% dextrose in 0.9% sodium chloride.
c. Balanced Multiple Maintenance Solution with 5% Dextrose.
d. 5% dextrose in 0.45% sodium chloride.
RATIONALE: A. 0.9% sodium chloride. 0.9% sodium chloride is a standard solution used to follow infusion of blood
products; Options B, C, and D: IV solution containing dextrose in water will hemolyze red cells.
9. Nurse Jay is caring for a client with an ongoing transfusion of packed RBC’s when suddenly the client is having
difficulty of breathing, skin is flushed and having chills. Which action should nurse Jay take first?
a. Administer oxygen.
b. Place the client on droplight.
c. Check the client’s temperature.
d. Stop the transfusion.
RATIONALE: D. Stop the transfusion. The client in this situation is experiencing transfusion reaction so the priority action
of the nurse is to first stop the transfusion.
10. After terminating the transfusion during a reaction, which action should the nurse immediately be taken next?
a. Run a solution of 5% dextrose in water.

b. Run normal saline at a keep-vein-open rate.
c. Remove the IV line.
d. Fast drip 200ml normal saline.
RATIONALE: B. Run normal saline at a keep-vein-open rate. The nurse will infuse normal saline at a KVO rate to keep the
patency of the IV line while waiting for further orders from the physician; Option A: IV solution containing dextrose will
hemolyze the red cells; Option C: The nurse will not remove the IV line because then there would be no IV access route;
Option D: Doing a fast drip will potentially lead to congestion and is not done without the physician order.
11. A client is receiving a platelet transfusion. The nurse determines that the client is gaining from this therapy if the
client exhibits which of the following?
a. Less frequent febrile episodes.

b. Increased level of hematocrit.
c. Less episodes of bleeding.
d. Increased level of hemoglobin.
RATIONALE: C. Less episodes of bleeding. Platelet transfusions may be given to prevent bleeding when the platelet
count falls down; Option A: A decline in the febrile episode will happen after the transfusion of agranulocytes; Options B
and D: An increased level of hemoglobin and hematocrit will happen after the transfusion of red blood cells.
12. Nurse Daniel is caring for a client receiving a transfusion of packed red blood cells (PRBCs). The client started to
vomit and to be nauseous. Client’s blood pressure is 95/40 mm Hg from a baseline of 110/70 mm Hg. The client’s
temperature is 100.5°F orally from a baseline of 99.5°F orally. The nurse understand that the client may be experiencing
which of the following?
a. Circulatory overload.
b. Delayed transfusion reaction.
c. Hypocalcemia.
d. Septicemia.
RATIONALE: D. Septicemia. Septicemia happens with the transfusion of blood that is contaminated with
microorganisms. Assessment includes rapid onset of high fever and chills, hypotension, nausea, diarrhea, vomiting, and
shock; Option A: Circulatory overload causes hypertension, cough, dyspnea, chest pain, tachycardia, and wheezing upon
auscultation; Option B: Delayed reaction can occur days to years after a transfusion. It causes, fever, rashes, mild
jaundice, and oliguria or anuria; Option C: Hypocalcemia causes paresthesias, tetany, muscle cramps, hyperactive
reflexes, positive Trousseau’s sign, and positive Chovstek’s sign.
13. Packed red blood cells have been prescribed for a client with low hemoglobin and hematocrit levels. The nurse takes
the client’s temperature before hanging the blood transfusion and records 100.8 °F. Which action should the nurse
take?
a. Give an antipyretic and begin the transfusion.

b. Proceed with the transfusion.
c. Administer an antihistamine and begin the transfusion.
d. Delay hanging the blood and inform the physician.
RATIONALE: D. Delay hanging the blood and inform the physician. If the client has a temperature higher than 100 ° F,
the unit of blood should be hung and delayed until the physician is notified and has the opportunity to give further
order; Options A and C are incorrect since the administration of the medicine will need the physician’s prescription;
Option B: The decision to administer the blood is not within the scope of nurse practice.
14. A nurse is caring for a client requiring surgery and is ordered to have a standby blood secured if in case a blood
transfusion is needed during or after the procedure. The nurse suggest to the client to do which of the following to
lessen the risk of possible transfusion reaction?
a. Request that any donated blood be screened twice by the blood bank.
b. Take iron supplement prior the surgery and eat green leafy vegetables.
c. Do an autologous blood donation.
d. Have a family member donate their own blood.
RATIONALE: C. Do an autologous blood donation. A donation of the own blood is autologous. Doing this will prevent the
risk of transfusion reaction.
15. A client is receiving transfusion of one unit of cryoprecipitate. The nurse will review which of the following laboratory
studies to assess the effectiveness of the therapy?
a. Serum electrolytes.
b. White blood cell count.
c. Coagulation studies.
d. Hematocrit count.
RATIONALE: C. Coagulation studies. The evaluation of an effective response of a cryoprecipitate transfusion is assessed
by monitoring coagulation studies and fibrinogen levels.
16. Transfusion Related Acute Lung Injury (TRALI): Leading cause of transfusion related mortality; Leakage of fluid into
alveolar space due to diffuse alveolar capillary damage; S/S: SOB, increase RR, Hypoxemia, hypotension, occasional
fever; Treatment: Oxygen, possible intubation & mechanical ventilation, possible fluids to treat hypotension.
17. Transfusion Associated Circulatory Overload (TACO): Volume overload temporally associated with transfusion; S/S:
SOB, increase RR, hypoxemia, Increased left atrial pressure, JVD, Elevated systolic pressure. Treatment: Oxygen,
possible intubation/ mechanical ventilation, Diuresis to reduce volume. Also consider MI
18. Reactions to Blood Transfusions: Fever, chills, itching, Hives (urticaria), anaphylaxis, chest pain, hypotension
19. autonomous: Your own blood draw and can be readmitted to you if needed (ex. scheduled surgery)
20. Blood typing: negative blood type (O-) can give to positive but you cannot give positive blood to negative blood.
21. hemoglobin and hematocrit lab levels ( left to right): Women 12:36 and Men 13:39
22. When to redraw labs?: redraw labs in between units of blood transfused. Typically within 1 hour.
23. When to assess: Assess vitals before, during, and after transfusion.
24. Cross match blood transfusion: Crossmatching is a way for your healthcare provider to test your blood against a
donor's blood to make sure they are fully compatible. Crossmatching takes 45 minutes to an hour. It's essentially a
trial transfusion done in test tubes to see exactly how your blood will react with potential donor blood.
25. When to transfuse?: When Hgb is below 7 or they are symptomatic
1. Red blood cells are very for vital survival. Which statement below is NOT correct about red blood cells?
A. “Red blood cells help carry oxygen throughout the body with the help of the protein hemoglobin.”
B. “Extreme loss of red blood cells can lead to a suppressed immune system and clotting problems.”
C. “Red blood cells help remove carbon dioxide from the body.”
D. “Red blood cells are suspended in the blood’s plasma.”
RATIONALE: The answer B. Extreme loss of red blood cells leads to anemia which can cause a patient to experience
shortness of breath (there is a decreased ability to carry oxygen throughout the body), tachycardia, fatigue, pale skin
color etc. Suppressed immune system can be from LOW white blood cells, and clotting problems can be from LOW
platelets.
2. You’re providing care to a 36 year old male. The patient experienced abdominal trauma and recently received 2 units
of packed red blood cells. You’re assessing the patient’s morning lab results. Which lab result below demonstrates that
the blood transfusion was successful?
A. Hemoglobin level 7 g/dL

B. Platelets 300,000 µl
C. Hemoglobin level 15 g/dL
D. Prothrombin Time 12.5 seconds
RATIONALE: The answer is C. Hemoglobin levels are used to assess the effectiveness of a blood transfusion. A normal
Hgb level for a MALE is 14 to 18 g/dL. For a FEMALE, the level is 12 to 16 g/dL.
3. According to the American Association of Blood Banks, what is the recommended hemoglobin level for a blood
transfusion?
A. 5-7 g/dL
B. 7-8 g/dL
C. 4-7 g/dL
D. 9-10 g/dL
RATIONALE: The answer is B. This is the recent recommendation for by the AABB (7-8 g/dL).
4. What blood type is known as the “universal donor”?
A. Type A
B. Type B
C. Type AB
D. Type O
RATIONALE: The answer is D. Type O is known as the universal donor.

5. What blood type is known as the “universal recipient”?
A. Type A
B. Type B
C. Type AB
D. Type O
RATIONALE: The answer is C. Type AB is known as the universal recipient.
6. A patient needs 2 units of packed red blood cells. The patient is typed and crossmatched. The patient has B+ blood. As
the nurse you know the patient can receive what type of blood? Select all that apply:
A. B-
B. A+
C. O-
D. B+
E. O+
F. A-
G. AB+
H. AB-
RATIONALE: The answers are A, C, D and E. The patient must receive blood from either a donor that has O or B blood.
Since the patient is B+ (Rh factor is positive), they can receive both negative or positive blood. So, the patient can
receive B-, B+, O-, and O+ blood.
7. A donor has AB- blood. Which patient or patients below can receive this type of blood safely?
A. A patient with O- blood.

B. A patient with A- blood.
C. A patient with B- blood.
D. A patient with AB- blood.
RATIONALE: The answer is D. Donors with AB type blood can only donate to others who have the AB type blood, in this
case AB- blood. However, they are the universal recipients in that they can receive blood for every blood type but can
only donate to their same exact blood type.
8. As the nurse you know that there is a risk of a transfusion reaction during the administration of red blood cells. Which
patient below it is at most RISK for a febrile (non-hemolytic) transfusion reaction?
A. A 38 year old male who has received multiple blood transfusions in the past year.
B. A 42 year old female who is immunocompromised.
C. A 78 year old male who is B+ that just received AB+ blood during a transfusion.
D. A 25 year old female who is AB+ and just received B+ blood.
RATIONALE: The answer is A. A febrile transfusion reaction is where the recipient’s WBCs are reacting with the donor’s
WBCs. This causes the body to build antibodies. It is most COMMON in patients who have received blood transfusion in
the past. Option B is at risk for GvHD (graft versus host disease). Option C is wrong because this places the patient at risk
for a hemolytic transfusion reaction (not febrile). The patient is receiving incompatible blood. However, option D is not
the patient at MOST risk compared to option A. Note the patient is receiving compatible blood. Note the patient is
receiving compatible blood in this option.
9. Before a blood transfusion you educate the patient to immediately report which of the following signs and symptoms
during the blood transfusion that could represent a transfusion reaction:
A. Sweating
B. Chills
C. Hives
D. Poikilothermia
E. Tinnitus
F. Headache
G. Back pain
H. Pruritus
I. Paresthesia
J. Shortness of Breath
K. Nausea
RATIONALE: The answers are A, B, C, F, G, H, J, and K. As the nurse you want to educate the patient to report signs and
symptoms associated with blood transfusion reactions, which would include: sweating, chills, hives, headache, back
pain, pruritus (itching), shortness of breath, and nausea.
10. Your patient needs 1 unit of packed red blood cells. You’ve completed all the prep and the blood bank notifies you
the patient’s unit of blood is ready. You send for the blood and the transporter arrives with the unit at 1200. You know
that you must start transfusing the blood within _________.
A. 5 minutes
B. 15 minutes
C. 30 minutes
D. 1 hour
RATIONALE: The answer is C. The blood must be started within 30 minutes.
11. A patient who needs a unit of packed red blood cells is ordered by the physician to be premeditated with oral
diphenhydramine and acetaminophen. You will administer these medications?
A. 15 minutes before starting the transfusion

B. Immediately after starting the transfusion
C. Right before starting the transfusion
D. 30 minutes before starting the transfusion
RATIONALE: The answer is D. For ORAL medications you will administer the medications 30 minutes before starting the
transfusion.
12. A patient is receiving 1 unit of packed red blood cells. The unit of blood will be done at 1200. The patient is
scheduled to have IV antibiotics at 1000. As the nurse you will:
A. Stop the blood transfusion and administer the IV antibiotic, and when the antibiotic is done resume the blood
transfusion.
B. Administer the IV antibiotic via secondary tubing into the blood transfusion’s y-tubing.
C. Hold the antibiotic until the blood transfusion is done.
D. Administer the IV antibiotic as scheduled in a second IV access site.
RATIONALE: The answer is D. If any IV medications will be needed while the blood is transfusing, the nurse will need to
start another IV access site. The nurse would NEVER administer the IV antibiotic in the same tubing as the blood product
or stop the transfusion. Remember blood is time sensitive and must be transfused within 4 hours. Also, holding the
antibiotic is not correct because antibiotics are time sensitive as well and must be administered at the scheduled time to
maintain blood levels.
13. You’re gathering supplies to start a blood transfusion. You will gather?
A. PVC free tubing and dextrose

B. Polyethylene-line tubing and 0.9% Normal Saline
C. Y-tubing with in-line filter and dextrose
D. Y-tubing with in-line and 0.9% Normal Saline
RATIONALE: The answer is D. This is the type of tubing and solution you will use to transfuse blood. Normal Saline is the
ONLY solution used to transfuse blood!!
14. A patient is ordered to receive 2 units of packed red blood cells. The first unit was started at 1400 and ended at
1800. You send for the other bag of red blood cells. As the nurse you know it is priority to:
A. obtain signed informed consent for the second unit of blood from the patient
B. obtain a new y-tubing set for this unit of blood
C. type and crossmatch the patient
D. hang a new bag of dextrose to transfuse with the blood
RATIONALE: The answer is B. The patient has already received 1 unit of blood and another unit is needed. It took 4
hours for the first unit to transfuse and the nurse needs to obtain new y-tubing for the next unit of blood. Y-tubing sets
are only good for 4 hours. Some hospitals require new tubing sets with each unit transfusion or after 4 hours….always
check your hospital’s protocol.
15. Before starting a blood transfusion the nurse will perform a verification process with __________. This will include?
A. any available personnel; physician’s order, patient’s identification, blood bank’s information, expiration date of
blood
B. licensed personnel only (another RN); physician’s order, patient’s identification, blood bank’s information,
patient’s blood type and donor’s type along with Rh factor, expiration date, assess the bag of blood for
damage or abnormal substances
C. blood bank; patient’s identification, blood bank’s information, patient’s blood type and donor’s type along with
Rh factor, expiration date, bag of blood for damage or abnormal substances
D. licensed personnel only (another RN); blood compatibility, physician order, expiration date
RATIONALE: The answer is B. The nurse will verify with another licensed personnel (another RN) the physician’s order,
patient’s identification and blood bank’s information, patient’s blood type and donor’s type along with the Rh factor,
expiration date, assess the bag for damage or abnormal substances BEFORE starting the transfusion.
16. Before initiating the blood transfusion, you obtain the patient’s baseline vital signs, which are: heart rate 100, blood
pressure 115/72, respiratory rate 18, and temperature 100.8’F. Your next action is to:
A. Administer the blood transfusion as ordered.

B. Hold the blood transfusion and reassess vital signs in 1 hour.
C. Notify the physician before starting the transfusion.
D. Administer 200 mL of the blood and then reassess the patient’s vital signs.
RATIONALE: The answer is C. The patient has an elevated temperature. Any temperature greater than 100’F (before the
administration of the blood) the physician should be notified.
17. You’ve started the first unit of packed red blood cells on a patient. You stay with the patient during the first 15
minutes and:
A. run the blood at 100 mL/min and then increase the rate after 15 minutes, if tolerated by the patient.
B. run the blood at 20 mL/min and then increase the rate after 15 minutes, if tolerated by the patient.
C. run the blood at 200 mL/min and then decrease the rate after 15 minutes, if tolerated by the patient.
D. run the blood at 2 mL/min and then increase the rate after 15 minutes, if tolerated by the patient.
RATIONALE: The answer is D. The blood will be started on an infusion pump at 2 mL/min, and if the blood is tolerated by
the patient, it will be increased AFTER 15 minutes. Remember the blood must be transfused within 2-4 hours….most
bags are 250 to 300 mL. During the first 15 minutes is when the patient is most likely to have a transfusion reaction.
Running the blood slowly during the first 15 minutes allows the patient to receive the LEAST amount of blood possible if
a reaction does occur.
18. A patient started receiving their first unit of blood at 1000. It is now 1010 and the patient is reporting itching, chills,
and a headache. In addition, the patient’s temperature is now 99.8’F from 98’F. Your next nursing action is:
A. Stop the transfusion

B. Notify the physician
C. Decrease the rate of the transfusion
D. Reassure the patient that this is normal and will resolve in 30 minutes.
RATIONALE: The answer is A. The patient is possibly having a transfusion reaction. FIRST, the nurse should STOP the
transfusion and then disconnect the IV tubing at the access site and replace it with NEW tubing. In addition, have normal
saline infusing to keep the vein open. THEN the nurse will notify the physician and blood bank.
19. What solution or solutions below are compatible with red blood cells?
A. Normal Saline
B. Dextrose Solutions
C. Any medications with normal saline
D. No solutions are compatible with blood
RATIONALE: The answer is A. Only NORMAL SALINE is compatible with blood.
20. A patient with O+ blood received A+ blood. The patient is at risk for?
A. Febrile transfusion reaction

B. None: O+ and A+ are compatible blood types
C. Hemolytic transfusion reaction
D. Allergic transfusion reaction
RATIONALE: The answer is C. O+ and A+ are NOT compatible blood types. Patients with O+ can only receive blood from
others with O blood. This patient is at risk for a hemolytic reaction. This is where the immune system is killing the donors
RBCs. The antibodies in the recipient’s blood match the antigens on the donor’s blood cells….the patient has been
mistyped!!
21. Your patient is having a transfusion reaction. You immediately stop the transfusion. Next you will:
A. Notify the physician.

B. Disconnect the blood tubing from the IV site and replace it with a new IV tubing set-up and keep the vein
open with normal saline 0.9%.
C. Collect urine sample.
D. Send the blood tubing and bag to the blood bank.
RATIONALE: The answer is B. This question wants to know your NEXT nursing action. AFTER stopping the transfusion,
the nurse will DISCONNECT the blood tubing from the IV site and replace it with a new IV tubing set-up and keep the
vein open with normal saline 0.9%. This will limit any more blood from entering the patient’s system. THEN the nurse
will notify the MD and blood bank.
1. Which action should be performed to avoid the most common cause of fatal transfusion reactions?
A. Establish vascular access.
B. Have two qualified health care professionals check the blood component information and the patient's
identification.
C. Keep the blood refrigerated until the time of transfusion.
D. Administer the blood over a 4-hour period.
RATIONALE: The most common cause of fatal transfusion reactions is type mismatches due to clerical error,
administration of blood to the wrong patient, or incorrect identification of the blood component. Having two qualified
health care professionals check the blood component information and the patient's identification is the best way to
avoid giving the wrong blood product to the wrong patient. Vascular access is required to administer blood products and
does not influence transfusion reactions. All blood or blood components that are not used immediately should be
returned to the blood bank or refrigerated until the time of transfusion and administered within 4 hours or less, but
failure to adhere to these guidelines is not the most common cause of fatal transfusion reactions.
2. A patient is being treated for burns. The transfusionist anticipates administering albumin to achieve which goal?
A. Facilitating blood coagulation

B. Restoring factor VIII levels
C. Treating acute hemorrhage
D. Replacing and maintaining intravascular volume
RATIONALE: Albumin is used to maintain normal colloid oncotic pressure and therefore intravascular volume. It does not
contain factor VIII, RBCs, or clotting components.
3. After running an FFP infusion slowly for the first 15 minutes to watch for any transfusion reactions, what should the
transfusionist do next?
A. Complete the infusion over 6 hours.

B. Run the infusion wide open until completed.
C. Decrease the infusion to a rate of 10 ml/hr.
D. Increase the infusion rate as desired.
RATIONALE: Assuming that no transfusion reaction is observed within the first 15 minutes, the transfusionist should
reassess vital signs and increase the infusion rate as desired. Most blood products, including FFP, should be infused
within 4 hours or less.
4. If a patient develops a skin rash, edema, and wheezing during a blood transfusion, what should the transfusionist do?
A. Discard the blood bag and tubing.

B. Decrease the rate of the transfusion.
C. Stop the transfusion immediately.
D. Reassess the patient in 10 minutes.
RATIONALE: Rash, edema, and wheezing are signs of an anaphylactic reaction, and the transfusion should be stopped
immediately. The transfusionist should continuously monitor the patient while summoning assistance and anticipating
epinephrine administration. The blood bag and tubing should be saved to return to the blood bank.
5. After spiking the blood component bag and filling the drip chamber to cover the filter, the transfusionist observes air
bubbles in the drip chamber. Which action should be taken next?
A. Infuse the blood component with no filter in the line.

B. Tap the filter chamber lightly.
C. Leave the existing air bubbles in the line.
D. Change the entire tubing.
RATIONALE: Tapping the filter chamber lightly causes the air bubbles to dissipate as they rise in the drip chamber. Blood
component is never administered without a filter or with visible air bubbles in the line. There is no need to change the
entire tubing and waste the blood component that is already in it when tapping will eliminate the problem.
6. During rapid resuscitation of a trauma patient, the blood filter has become clogged. What is the most appropriate
intervention?
A. Squeeze the filter.

B. Use a rapid infuser.
C. Flush the IV line with a 0.9% sodium chloride solution.
D. Change the filter.
RATIONALE: A clogged filter must be changed to facilitate effective blood transfusion. Squeezing the filter and flushing
the IV line do not help unclog the filter. A rapid infuser may be used to transfuse blood but does not help when a filter is
clogged.
7. Obtaining IV access is an important intervention before administering blood products. Which statement made by a
new nurse indicates understanding of adequate IV access?
A. "I should not use a 25-G IV catheter for rapid infusion of cellular components."
B. "Larger gauge needles are optimal for slow rates of infusion."
C. "I will use a 14- to 18-G IV catheter for rapid infusion of a cellular component."
D. "Smaller gauge needles allow for rapid rates of infusion."
RATIONALE: When planning to infuse products containing cellular components (i.e., RBCs or WBCs), a 14- to 18-G
catheter is used for rapid administration of product. Elective administration may be given with small catheters. Needles
and IV catheters used for infusion of cellular components may be as small as 25-G.
8. A TRALI is a serious complication that can occur with blood transfusions. What are the characteristics of TRALI?
A. TRALI occurs within 1 to 2 hours of the transfusion, activates the complement cascade, and decreases histamine
release.
B. TRALI occurs anytime during the transfusion to 6 hours after transfusion, activates the complement cascade,
and increases histamine release.
C. TRALI occurs within 8 hours of the transfusion, activates the complement cascade, and increases histamine
release.
D. TRALI occurs within 8 hours of the transfusion, activates the complement cascade, and decreases histamine
release.
RATIONALE: TRALI occurs anytime during the transfusion to 6 hours after transfusion. It manifests as noncardiogenic
pulmonary edema. The reaction activates the complement cascade and histamine release, leading to increased
pulmonary capillary permeability.
9. Why are infusions of blood products started slowly?
A. A slow start allows adequate time for platelets to thaw.

B. A slow start allows adequate time for removing an air bubble in the tubing
C. A slow start allows adequate time to obtain baseline vital signs.
D. Adverse reactions can occur with exposure to small amounts of blood products.
RATIONALE: Transfusion reactions can be life threatening and occur with exposure to even a small amount of blood;
therefore, transfusions should be started slowly unless the patient's condition requires a rapid, life-sustaining
transfusion. Platelets should be stored at room temperature, and never refrigerated or frozen. The presence of an air
bubble should be noted and corrected during priming of the blood tubing and before connection of the administration
set. Baseline vital signs should be obtained before initiation of the transfusion.
10. What is one of the indications for the administration of cryoprecipitate?
A. To replace clotting factors for patients who have factor VIII or factor XIII deficiencies
B. To maintain normal colloid oncotic pressure
C. To prevent transfusion-related GVH reactions
D. To control bleeding due to thrombocytopenia
RATIONALE: Cryoprecipitated antihemophilic factor (cryoprecipitate) is given to control bleeding by replacing clotting
factors in the presence of factor VIII or factor XIII deficiency, von Willebrand disease, hypofibrinogenemia, or
disseminated intravascular coagulation. The primary function of colloid components such as albumen is to maintain
normal colloid oncotic pressure. Irradiated blood products are cellular components that have been treated with
radiation to prevent TAGVHD reactions in certain immunocompromised populations. Platelets are given to prevent or
help control bleeding due to thrombocytopenia, dysfunctional platelet disorders, active platelet-related bleeding, or in
cases where there is a serious risk of bleeding.
11. What blood product might be considered for administration to a neutropenic patient with a severe bacterial
infection who is not responding to antibiotics?
A. Platelets
B. Albumin
C. Granulocytes
D. Cryoprecipitate
RATIONALE: Granulocytes are white blood cells and aid in fighting infection by surrounding and killing bacteria. They
may be considered for a neutropenic patient with infection. Platelets aid in clotting. Albumin is helpful for volume
expansion, and cryoprecipitate is administered for those with deficiencies in specific clotting factors.
1. A nurse reviews the arterial blood gas results of a client and notes the following: pH 7.45, Pco2 of 30, and HCO3- of
22. The nurse analyzes these results as indicating which condition?
a. Metabolic Acidosis, compensated

b. Respiratory Alkalosis, compensated
c. Metabolic Alkalosis, compensated
d. Respiratory Acidosis, compensated
RATIONALE: The normal pH is 7.3-7.45. In a respiratory condition, an opposite effect will be seen between the pH and
the Pco2. In this condition, the pH is a the high end of normal and the Pco2 is low. In an alkalotic condition, the pH is
elevated. Therefore the values identified in the question indicated a respiratory alkalosis. When the pH returns to a
normal value, compensation has occurred.
2. A nurse is caring for a client with a nasogastric tube that is attached to low suction. The nurse monitors the client,
knowing that the client is at risk for which acid-base disorder?
a. Metabolic Acidosis
b. Metabolic Alkalosis
c. Respiratory Acidosis
d. Respiratory Alkalosis
RATIONALE: Metabolic Alkalosis is defined as a deficit or loss of hydrogen ions or acids or an excess of base
(bicarbonate) that results from the accumulation of base or from a loss of acid without a comparable loss of base in the
body fluids. This occurs in conditions resulting in hypovolemia, the loss of gastric fluid, excessive bicarbonate intake, the
massive transfusion of whole blood, and hyperaldosteronism. Loss of gastric fluid via nasogastric suction or vomiting
causes Metabolic Alkalosis as a result of the loss of hydrochloric acid. Options 1, 3, & 4 are incorrect interpretations.
3. A client with a 3-day history of nausea and vomiting presents to the emergency department. The client is
hypoventilating and has a respiratory rate of 10 breaths/min. Arterial blood gases are drawn and the nurse reviews the
results, expecting to note which of the following?
a. A decreased pH and an increased CO2

b. An increased pH and a decreased Co2
c. A decreased pH and a decreased HCO3-
d. An increased pH with an increased HCO3-
RATIONALE: Clients experiencing nausea and vomiting would most likely present with metabolic alkalosis resulting from
loss of gastric acid, thus causing the pH and HCO3- to increase. Symptoms experienced by the client would include
hypventilation and tachycardia. Option 2 reflects a respiratory acidotic condition. Option 2 reflects a respiratory alkalotic
condition. Option 3 reflects a metabolic acidotic condition.
4. A nurse caring for a client with an ileostomy understands the the client is most at risk for developing which acid-base
disorder?
RATIONALE: Metabolic Acidosis is defined as total concentration of buffer base that is lower than normal, with a relative
increase in the hydrogen ion concentration. This results from loss of buffer bases or the retention of too many acids
without sufficient bases, and occurs in conditions such as renal failure, diabetic ketoacidosis, from the production of
lactic acid, from the ingestion of toxins (such as acetylsalicylic acid -aka- aspirin), malnutrition, or severe diarrhea.
Intestinal secretions are high in bicarbonate and may e lost through enteric drainage tubes or an ileostomy, or with
diarrhea. These conditions result in metabolic acidosis. Options 2, 3, & 4 are incorrect interpretations and do not occur
in the client with an ileostomy.
**(Base/Bicarbonate is lost through an ileostomy)
5. A nurse is caring for a client with diabetic ketoacidosis and documents the the client is experiencing Kussmaul's
respirations. Based on this documentation, which of the following did the nurse observe?
a. Respirations that cease for several seconds

b. Respirations that are regular but abnormally slow
c. Respirations that are labored and increased in depth and rate
d. Respirations that are abnormally deep, regular, and increased in rate
RATIONALE: Kussmal's respirations are abnormally deep, regular, and increased in rate. Apnea is described as
repirations that cease for several seconds. In bradypnea, respirations are regular but abnormally slow. In hyperpnea,
respirations are labored and increased in depth and rate.
6. A client who is found unresponsive has arterial blood gases drawn and the results indicate dthe following: pH is 7.12,
Pco2 is 90, and HCO3- is 22. the nurse interprets the results as indicating which condition?
a. Metabolic Acidosis with compensation

b. Respiratory Acidosis with compensation
c. Metabolic Acidosis without compensation
d. Respiratory Acidosis without compensation
RATIONALE: The acid-base disturbance is respiratory acidosis without compensation. The normal pH is 7.35-7.45. The
normal Pco2 is 32-48. In respiratory acidosis the pH is decreased and the pco2 is elevated. The normal bicarbonate
(HCO3-) level is 22-27. Because the bicarbonate is still within normal limits, the kidneys have not had time to adjust for
this acid-base disturbance. Additionally, the pH is not within normal limits. Therefore the condition is without
compensation. Options 1, 2, & 3 are incorrect interpretations.
7. The nurse plans care for a client with chronic obstructive pulmonary disease (COPD), understanding that the client is
most likely to experience what type of acid-bases imbalance:
RATIONALE: Respiratory Acidosis is most often caused by hypoventilation in a client with COPD. Other acid-base
disturbances can occur in a client with COPD during exacerbation of the disease but the most likely imabalance is
respiratory acidosis. Option 1, 2,& 4 are incorrect options.
8. A nurse reviews the blood gas results of a client with atelectasis. The nurse analyzes the results and determines that
the client is experiencing respiratory acidosis. Which of the following validates the nurse's findings?
a. pH 7.25, Pco2 50,

b. pH 7.35, Pco2 40
c. pH 7.50, Pco2 52
d. pH 7.52, Pco2 28
RATIONALE: Atelectasis is a condition characterized by the collapse of alveoli, preventing the respiratory exchange of
oxygen and carbon dioxide in a part of the lungs. The normal pH is 7.35-7.45. The normal Pco2 is 32-48. In respiratory
acidosis, the pH is decreased and the Pco2 is elevated. Option 2 identifies normal values. Option 3 identifies an alkalotic
condition. Option 4 identifies respiratory alkalosis.
9. A nurse is caring for a client who is on a mechanical ventilator. Blood gas results indicated a pH of 7.50 and a Pco2 of
30. The nurse has determines that the client is experience respiratory alkalosis. Which laboratory value would most
likely be noted in this condition?
a. Sodium level of 145

b. Potassium level of 3
c. Magnesium level of 2
d. Phosphorus level of 4
RATIONALE: Respiratory alkalosis is defined as a deficit of carbonic acid or a decrease in hydrogen ion concentrations
that results from the accumulations of base or from a loss of acid without a comparable loss of base in the body fluids.
This occurs in conditions that cause overstimulation of the respiratory system. Clinical manifestations of repiratory
alkalosis include headache, tachypnea, paresthesias, tetany, vertigo, convusions, hypkalemia, and hypocalcemia.
Options 1, 3, & 4 identify normal laboratory values. Option 2 identifies the presence of hypokalemia.
10. A nurse notes that a client's arterial blood gas reults reveal a pH of 7.50 and a Pco2 of 30. The nurse monitors the
client for which clinical manifestations associated with these arterial blood gas results?
Select all the apply:
a. Nausea
b. Confusion
c. Bradypnea
d. Tachycardia
e. Hyperkalemia
f. Lightheadedness
RATIONALE: Respiratory alkalosis is defined as a deficit of carbonic acid or a decrease in hydrogen ion concentrations
that results from the accumulations of base or from a loss of acid without a comparable loss of base in the body fluids.
This occurs in conditions that cause overstimulation of the respiratory system. Clinical manifestations of repirtory
alkalosis include lethargy, lightheadedness, confusion, tachycardia, dysrhythmias related to hypokalemai, nausea,
vomiting, epigastric pain, and numbness and tingling of the extremities. Hyperventilation (tachypnea) occurs.
1. George Kent is a 54-year-old widower with a history of chronic obstructive pulmonary disease and was rushed to the
emergency department with increasing shortness of breath, pyrexia, and a productive cough with yellow-green sputum.
He has difficulty communicating because of his inability to complete a sentence. One of his sons, Jacob, says he has been
unwell for three days. Upon examination, crackles and wheezes can be heard in the lower lobes; he has tachycardia and
a bounding pulse. Measurement of arterial blood gas shows pH 7.3, PaCO2 68 mm Hg, HCO3 28 mmol/L, and PaO2 60
mm Hg. How would you interpret this?
A. Respiratory Acidosis, Uncompensated

B. Respiratory Acidosis, Partially Compensated
C. Metabolic Alkalosis, Uncompensated
D. Metabolic Acidosis, Partially Compensated
RATIONALE: B. Respiratory Acidosis, Partially Compensated - The patient has respiratory acidosis (raised carbon dioxide)
resulting from an acute exacerbation of chronic obstructive pulmonary disease, with partial compensation.
2. Carl, an elementary student, was rushed to the hospital due to vomiting and a decreased level of consciousness. The
patient displays slow and deep (Kussmaul breathing), and he is lethargic and irritable in response to stimulation. He
appears to be dehydrated—his eyes are sunken and mucous membranes are dry—and he has a two-week history of
polydipsia, polyuria, and weight loss. Measurement of arterial blood gas shows pH 7.0, PaO2 90 mm Hg, PaCO2 23 mm
Hg, and HCO3 12 mmol/L; other results are Na+ 126 mmol/L, K+ 5 mmol/L, and Cl- 95 mmol/L. What is your assessment?

D. Metabolic Acidosis, Partially, Compensated
RATIONALE: D. Metabolic Acidosis, Partially, Compensated - The student was diagnosed with diabetes mellitus. The
results show that he has metabolic acidosis (low HCO3 -) with respiratory compensation (low CO2).
3. A cigarette vendor was brought to the emergency department of a hospital after she fell into the ground and hurt her
left leg. She is noted to be tachycardic and tachypneic. Painkillers were carried out to lessen her pain. Suddenly, she
started complaining that she is still in pain and now experiencing muscle cramps, tingling, and paraesthesia.
Measurement of arterial blood gas reveals pH 7.6, PaO2 120 mm Hg, PaCO2 31 mm Hg, and HCO3 25 mmol/L. What
does this mean?
A. Respiratory Alkalosis, Uncompensated

D. Metabolic Alkalosis, Partially Compensated
RATIONALE: A. Respiratory Alkalosis, Uncompensated - The primary disorder is acute respiratory alkalosis (low CO2) due
to the pain and anxiety causing her to hyperventilate. There has not been time for metabolic compensation.
4. Ricky’s grandmother has been suffering from persistent vomiting for two days now. She appears to be lethargic and
weak and has myalgia. She is noted to have dry mucus membranes and her capillary refill takes >4 seconds. She is
diagnosed as having gastroenteritis and dehydration. Measurement of arterial blood gas shows pH 7.5, PaO2 85 mm Hg,
PaCO2 40 mm Hg, and HCO3 34 mmol/L. What acid-base disorder is shown?
A. Respiratory Alkalosis, Uncompensated
RATIONALE: C. Metabolic Alkalosis, Uncompensated - The primary disorder is uncompensated metabolic alkalosis (high
HCO3 -). As CO2 is the strongest driver of respiration, it generally will not allow hypoventilation as compensation for
metabolic alkalosis.
5. Mrs. Johansson, who had undergone surgery in the post-anesthesia care unit (PACU), is difficult to arouse two hours
following surgery. Nurse Florence in the PACU has been administering Morphine Sulfate intravenously to the client for
complaints of post-surgical pain. The client’s respiratory rate is 7 per minute and demonstrates shallow breathing. The
patient does not respond to any stimuli. The nurse assesses the ABCs (remember Airway, Breathing, Circulation!) and
obtains ABGs STAT! Measurement of arterial blood gas shows pH 7.10, PaCO2 70 mm Hg, and HCO3 24 mEq/L. What
does this mean?
A. Respiratory Alkalosis, Partially Compensated

B. Respiratory Acidosis, Uncompensated
C. Metabolic Alkalosis, Partially Compensated
D. Metabolic Acidosis, Uncompensated
RATIONALE: B. Respiratory Acidosis, Uncompensated - The results show that Mrs. Johansson has respiratory acidosis
because of decreased pH and increased PaCO2 which means acidic in nature. Meanwhile, it is uncompensated because
HCO3 is within the normal range.
6. Baby Angela was rushed to the Emergency Room following her mother’s complaint that the infant has been irritable,
difficult to breastfeed, and has had diarrhea for the past 3 days. The infant’s respiratory rate is elevated and the
fontanels are sunken. The Emergency Room physician orders ABGs after assessing the ABCs. The results from the ABG
results show pH 7.39, PaCO2 27 mmHg, and HCO3 19 mEq/L. What does this mean?
A. Respiratory Alkalosis, Fully Compensated

B. Metabolic Acidosis, Uncompensated
C. Metabolic Acidosis, Fully Compensated
D. Respiratory Acidosis, Uncompensated
RATIONALE: C. Metabolic Acidosis, Fully Compensated - Baby Angela has metabolic acidosis due to decreased HCO3 and
slightly acidic pH. Her pH value is within the normal range which made the result fully compensated.
7. Mr. Wales, who underwent post-abdominal surgery, has a nasogastric tube. The nurse on duty notes that the
nasogastric tube (NGT) is draining a large amount (900 cc in 2 hours) of coffee ground secretions. The client is not
oriented to person, place, or time. The nurse contacts the attending physician and STAT ABGs are ordered. The results
from the ABGs show pH 7.57, PaCO2 37 mmHg and HCO3 30 mEq/L. What is your assessment?
A. Metabolic Acidosis, Uncompensated

B. Metabolic Alkalosis, Uncompensated
C. Respiratory Alkalosis, Uncompensated
RATIONALE: B. Metabolic Alkalosis, Uncompensated - The postoperative client’s ABG results show that he has metabolic
alkalosis because of an increased pH and HCO3. It is uncompensated due to the normal PaCO2 which is within 35 to 45
mmHg.
8. Client Z is admitted to the hospital and is to undergo brain surgery. The client is very anxious and scared of the
upcoming surgery. He begins to hyperventilate and becomes very dizzy. The client loses consciousness and the STAT
ABGs reveal pH 7.61, PaCO2 22 mmHg, and HCO3 25 mEq/L. What is the ABG interpretation based on the findings?
A. Metabolic Acidosis, Uncompensated

B. Respiratory Alkalosis, Partially Compensated
RATIONALE: C. Respiratory Alkalosis, Uncompensated - The results show that client Z has respiratory alkalosis since
there is an increase in the pH value and a decrease in PaCO2 which are both basic. It is uncompensated due to the
normal HCO3 which is within 22-26 mEq/L.
9. Three-year-old Adrian is admitted to the hospital with a diagnosis of asthma and respiratory distress syndrome. The
mother of the child reports to the nurse on duty that she has witnessed slight tremors and behavioral changes in her
child over the past four days. The attending physician orders routine ABGs following an assessment of the ABCs. The
ABG results are pH 7.35, PaCO2 72 mmHg, and HCO3 38 mEq/L. What acid-base disorder is shown?

B. Respiratory Acidosis, Fully Compensated
C. Respiratory Alkalosis, Fully Compensated
RATIONALE: B. Respiratory Acidosis, Fully Compensated - The patient has respiratory acidosis (raised carbon dioxide)
resulting from asthma and respiratory distress syndrome, with compensation having normal pH value within 7.35to
7.45, increased PaCO2 which is acidic and increased HCO3 which is basic.
10. Anne, who is drinking beer at a party, falls and hits her head on the ground. Her friend Liza dials “911” because Anne
is unconscious, depressed ventilation (shallow and slow respirations), rapid heart rate, and is profusely bleeding from
both ears. Which primary acid-base imbalance is Anne at risk for if medical attention is not provided?
A. Metabolic Acidosis
B. Metabolic Alkalosis
C. Respiratory Acidosis
D. Respiratory Alkalosis
RATIONALE: C. Respiratory Acidosis - One of the risk factors of having respiratory acidosis is hypoventilation which may
be due to brain trauma, coma, and hypothyroidism or myxedema. Other risk factors include COPD, Respiratory
conditions such as pneumothorax, pneumonia, and status asthmaticus. Drugs such as Morphine and MgSO4 toxicity are
also risk factors of respiratory acidosis.
11. Dave, a 6-year-old boy, was rushed to the hospital following her mother’s complaint that her son has been vomiting,
nauseated and has overall weakness. After a series of tests, the nurse notes the laboratory results: potassium: 2.9 mEq.
Which primary acid-base imbalance is this boy at risk for if medical intervention is not carried out?
A. Respiratory Acidosis
B. Respiratory Alkalosis
C. Metabolic Acidosis
D. Metabolic Alkalosis
RATIONALE: D. Metabolic Alkalosis - Vomiting, hypokalemia, overdosage of NaHCO3 and NGT suctioning are considered
risk factors of metabolic alkalosis.
12. An old beggar was admitted to the emergency department due to shortness of breath, fever, and a productive
cough. Upon examination, crackles and wheezes are noted in the lower lobes; he appears to be tachycardic and has a
bounding pulse. Measurement of arterial blood gas shows pH 7.2, PaCO2 66 mm Hg, HCO3 27 mmol/L, and PaO2 65 mm
Hg. As a knowledgeable nurse, you know that the normal value for pH is:
A. 7.20
B. 7.30
C. 7.40
D. 7.50
RATIONALE: C. 7.40 - Normal blood pH must be maintained within a narrow range of 7.35-7.45 to ensure the proper
functioning of metabolic processes and the delivery of the right amount of oxygen to tissues. Acidosis refers to an excess
of acid in the blood that causes the pH to fall below 7.35, and alkalosis refers to an excess of base in the blood that
causes the pH to rise above 7.45.
13. Liza’s mother is seen in the emergency department at a community hospital. She admits that her mother is taking
many tablets of aspirin (salicylates) over the last 24-hour period because of a severe headache. Also, the mother
complains of an inability to urinate. The nurse on duty took her vital signs and noted the following: Temp = 97.8 °F;
apical pulse = 95; respiration = 32 and deep. Which primary acid-base imbalance is the client at risk for if medical
attention is not provided?
RATIONALE: C. Metabolic Acidosis - Salicylate overdose causes a high anion gap metabolic acidosis in both children and
adults. Adults commonly develop a mixed acid-base disorder as a respiratory alkalosis due to direct respiratory center
stimulation occurs as well. This second disorder is uncommon in children.
14. A patient who is hospitalized due to vomiting and a decreased level of consciousness displays slow and deep
(Kussmaul breathing), and he is lethargic and irritable in response to stimulation. The doctor diagnosed him of having
dehydration. Measurement of arterial blood gas shows pH 7.0, PaO2 90 mm Hg, PaCO2 22 mm Hg, and HCO3 14
mmol/L; other results are Na+ 120 mmol/L, K+ 2.5 mmol/L, and Cl- 95 mmol/L. As a knowledgeable nurse, you know that
the normal value for PaCO2 is:
A. 22 mm Hg
B. 36 mm Hg
C. 48 mm Hg
D. 50 mm Hg
RATIONALE: B. 36 mm Hg - The normal range for PaCO2 is from 35 to 45 mm Hg.
15. A company driver is found at the scene of an automobile accident in a state of emotional distress. He tells the
paramedics that he feels dizzy, tingling in his fingertips, and does not remember what happened to his car. Respiratory
rate is rapid at 34/minute. Which primary acid-base disturbance is the young man at risk for if medical attention is not
provided?
RATIONALE: B. Respiratory Alkalosis - Hyperventilation is typically the underlying cause of respiratory alkalosis.
Hyperventilation is also known as overbreathing. When someone is hyperventilating, they tend to breathe very deeply
or very rapidly.
16. An elderly client was admitted to hospital in a coma. Analysis of the arterial blood gave the following values: PCO2
16 mm Hg, HCO3- 5 mmol/L and pH 7.1. As a well-rounded nurse, you know that the normal value for HCO3 is:
A. 20 mmol/L
B. 24 mmol/L
C. 29 mmol/L
D. 31 mmol/L
RATIONALE: B. 24 mmol/L - The normal value for bicarbonate (HCO3) is 22-26 mmol/L or mEq/L. It may vary slightly
among different laboratories. The given values show the common measurement range of results for these tests. Some
laboratories use different measurements or may test different specimens.
17. In a patient undergoing surgery, it was vital to aspirate the contents of the upper gastrointestinal tract. After the
operation, the following values were acquired from an arterial blood sample: pH 7.55, PCO2 52 mm Hg and HCO3- 40
mmol/l. What is the underlying disorder?
RATIONALE: D. Metabolic Alkalosis - NGT suctioning, vomiting, hypokalemia and overdosage of NaHCO3 are considered
risk factors of metabolic alkalosis.
18. A mountaineer attempts an assault on a high mountain in the Andes and reaches an altitude of 5000 meters (16,400
ft) above sea level. What will happen to his arterial PCO2 and pH?
A. Both will be lower than normal.

B. The pH will rise and PCO2 will fall.
C. Both will be higher than normal due to physical exertion.
D. The pH will fall and PCO2 will rise
RATIONALE: B. The pH will rise and PCO2 will fall. - The mountaineer will suffer from a respiratory alkalosis. The decline
in the PO2 with altitude will stimulate breathing to offset the hypoxia. Carbon dioxide is driven from the blood faster
than it is produced in the tissues so PCO2 falls and pH rises.
19. A young woman is found comatose, having taken an unknown number of sleeping pills an unknown time before. An
arterial blood sample yields the following values: pH 6.90, HCO3- 13 meq/liter, and PaCO2 68 mmHg. This patient’s acid-
base status is most accurately described as:
B. Respiratory Acidosis
C. Simultaneous Respiratory and Metabolic Acidosis
D. Respiratory Acidosis with Complete Renal Compensation
RATIONALE: C. Simultaneous Respiratory and Metabolic Acidosis - Whenever the PCO2 and HCO3 are abnormal in
opposite directions, ie, one above normal while the other is reduced, a mixed respiratory and metabolic acid-base
disorder exists. When the PCO2 is elevated and the [HCO3-] reduced, respiratory acidosis and metabolic acidosis coexist.
20. A mother is admitted to the emergency department following complaints of fever and chills. The nurse on duty took
her vital signs and noted the following: Temp = 100 °F; apical pulse = 95; respiration = 20 and deep. Measurement of
arterial blood gas shows pH 7.37, PaO2 90 mm Hg, PaCO2 40 mm Hg, and HCO3 24 mmol/L. What is your assessment?
A. Hyperthermia
B. Hyperthermia and Respiratory Alkalosis
C. Hypothermia
D. Hypothermia and Respiratory Alkalosis
RATIONALE: A. Hyperthermia - An individual is considered to have hyperthermia if he or she has a temperature of >37.5
or 38.3 °C (99.5 or 100.9 °F). The measurement of arterial blood gases are normal.
1. In acid-base balance, the normal plasma PCO2 and bicarbonate levels are disturbed. Match the changes in this
parameter with the disorders in the given choices: Low plasma PaCO2
C. Metabolic Alkalosis
D. Respiratory Acidosis
RATIONALE: B. Respiratory Alkalosis - Excessive pulmonary ventilation decreases hydrogen ion concentration and thus
causes respiratory alkalosis. It can become dangerous when it leads to cardiac dysrhythmias caused partly by a decrease
in serum potassium levels.
parameter with the disorders in the given choices: High plasma PaCO2
RATIONALE: D. Respiratory Acidosis - An excess of carbon dioxide (hypercapnia) can cause carbon dioxide narcosis. In
this condition, carbon dioxide levels are so high that they no longer stimulate respirations but depress them.
parameter with the disorders in the given choices: Decreased plasma bicarbonate (HCO3-)
RATIONALE: A. Metabolic Acidosis - The body compensates by using body fat for energy, producing abnormal amounts
of ketone bodies. In an effort to neutralize the ketones and maintain the acid-base balance of the body, plasma
bicarbonate is exhausted. This condition can develop in anyone who does not eat an adequate diet and whose body fat
must be burned for energy. Symptoms include headache and mental dullness.
parameter with the disorders in the given choices: Increased plasma bicarbonate (HCO3-)
RATIONALE: C. Metabolic Alkalosis - In metabolic alkalosis, breathing becomes depressed in an effort to conserve carbon
dioxide for combination with water in the blood to raise the blood level of carbonic acid. Symptoms include confusion,
dizziness, numbness or tingling of fingers or toes.
5. What two organs in the body serve as a compensatory function to maintain acid-base balance?
A. Kidneys and Lungs

B. Lungs and Spleen
C. Heart and Liver
D. Gallbladder and Appendix
RATIONALE: A. Kidneys and Lungs - The carbonic acid concentration is controlled by the amount of carbon dioxide
excreted by the lungs. The bicarbonate concentration is controlled by the kidneys, which selectively retain or excrete
bicarbonate in response to the body’s needs.
6. Arterial blood gas (ABG) measurement will give the information needed to determine if the primary disturbance of
acid-base balance is respiratory or metabolic in nature.
A. True
B. False
C. Both Carbonic Acid Excess and Deficit Only
D. Both Bicarbonate Excess and Deficit Only
RATIONALE: A. True - ABG’s are blood tests that are useful in identifying the cause and extent of the acid-base
disturbance and in guiding and monitoring treatment.
7. The major effect of acidosis is overexcitement of the central nervous system.
A. True
B. False
C. Maybe
D. Both Acidosis and Alkalosis result in overexcitement of the central nervous system.
RATIONALE: B. False - The major effect is a depression of the central nervous system, as evidenced by disorientation
followed by coma.
8. Alkalosis is characterized by overexcitement of the nervous system.
A. True
B. False
C. The major effect of Alkalosis is a depression of the central nervous system.
D. Both Acidosis and Alkalosis result in overexcitement of the central nervous system.
RATIONALE: A. True - The muscles may go into a state of tetany and convulsions.
9. The human body functions optimally in a state of homeostasis.
A. True
B. False
C. Maybe
D. Homeostasis has nothing to do with metabolic balance.
RATIONALE: A. True - The maintenance of acid-base balance, which in one part of homeostasis, is evidenced by an
arterial plasma pH value of 7.35-7.45. Many mechanisms in the body work together to achieve and maintain this delicate
narrow range of pH that is essential for normal cell function.
10. Acids have no hydrogen ions and are able to bind in a solution.
A. True
B. False
C. Acid is a substance that is not capable of donating hydrogen ions.
D. Acids and bases have nothing to do with hydrogen ions.
RATIONALE: B. False - Acids are substances having one or more hydrogen ions that can be liberated into a solution;
Bases are substances that can bind hydrogen ions in a solution.
11. Match the acid-base status of the following blood samples to the disorders in the given choices. (PaCO2 values are in
mm Hg and bicarbonate values in mmol/l). pH 7.57, PaCO2 22, HCO3- 17
A. Respiratory Acidosis, Partially Compensated

B. Respiratory Alkalosis, Uncompensated
C. Metabolic Acidosis, Partially Compensated
D. Respiratory Alkalosis, Partially Compensated
RATIONALE: D. Respiratory Alkalosis, Partially Compensated - Based on the given ABG values, pH is 7.57. For pH, the
normal range is 7.35 to 7.45. Any blood pH above 7.45 (7.46, 7.47, 7.48, and so on…) is ALKALOSIS; PaCO2 is 22. The
normal range for PaCO2 is from 35 to 45. If PaCO2 is below 35, it is alkalosis. Based on the given ABG values, PaCO2 is
below 35, so it is considered ALKALOSIS; HCO3- is 17. The normal range for HCO3 is from 22 to 26. If HCO3 is below 22, it
is acidosis. Based on the given ABG values, HCO3 is below 22, so it is considered ACIDOSIS; For these ABG values, pH is
ALKALOSIS and lines up with PaCO2 which is RESPIRATORY. Therefore, this group of ABG values is considered
RESPIRATORY ALKALOSIS; Lastly, it is PARTIALLY COMPENSATED because all three (3) values are abnormal. It is
considered partially compensated if all three (3) values are abnormal.
B. Metabolic Acidosis
C. Respiratory Alkalosis
E. Normal
RATIONALE: E. Normal - Based on the given ABG values, pH is 7.39. For pH, the normal range is 7.35 to 7.45. So it is
NORMAL; PaCO2 is 44. The normal range for PaCO2 is from 35 to 45. It is also NORMAL; HCO3- is 26. The normal range
for HCO3 is from 22 to 26. It is also NORMAL; For these ABG values, pH, PACO2, and HCO3 are NORMAL. Therefore, this
group of ABG values is considered NORMAL.

B. Respiratory Alkalosis, Uncompensated
D. Metabolic Acidosis, Uncompensated
RATIONALE: B. Respiratory Alkalosis, Uncompensated - Based on the given ABG values, pH is 7.55. For pH, the normal
range is 7.35 to 7.45. Any blood pH above 7.45 (7.46, 7.47, 7.48, and so on…) is ALKALOSIS; PaCO2 is 25. The normal
range for PaCO2 is from 35 to 45. If PaCO2 is below 35, it is alkalosis. Based on the given ABG values, PaCO2 is below 35,
so it is considered ALKALOSIS; HCO3- is 22. The normal range for HCO3 is from 22 to 26. It is NORMAL; For these ABG
values, pH is ALKALOSIS and lines up with PaCO2 which is RESPIRATORY. Therefore, this group of ABG values is
considered RESPIRATORY ALKALOSIS; Lastly, it is UNCOMPENSATED because HCO3 is normal and PaCO2 is abnormal. It is
uncompensated if PaCO2 or HCO3 is normal and the other is abnormal.

B. Metabolic Acidosis, Partially Compensated
C. Respiratory Alkalosis, Partially Compensated
D. Respiratory Acidosis, Partially Compensated
RATIONALE: D. Respiratory Acidosis, Partially Compensated - Based on the given ABG values, pH is 7.17. For pH, the
normal range is 7.35 to 7.45. Any blood pH below 7.35 (7.34, 7.33, 7.32, and so on…) is ACIDOSIS; PaCO2 is 48. The
normal range for PaCO2 is from 35 to 45. If PaCO2 is above 45, it is acidosis. Based on the given ABG values, PaCO2 is
above 45, so it is considered ACIDOSIS; HCO3- is 36. The normal range for HCO3 is from 22 to 26. If HCO3 is above 26, it
is alkalosis. Based on the given ABG values, HCO3 is above 26, so it is considered ALKALOSIS; For these ABG values, pH is
ACIDOSIS and lines up with PaCO2 which is RESPIRATORY. Therefore, this group of ABG values is considered
RESPIRATORY ACIDOSIS; Lastly, it is PARTIALLY COMPENSATED because all three (3) values are abnormal. It is considered
partially compensated if all three (3) values are abnormal.

B. Metabolic Acidosis, Partially Compensated
C. Metabolic Acidosis, Uncompensated
RATIONALE: B. Metabolic Acidosis, Partially Compensated - Based on the given ABG values, pH is 7.34. For pH, the
normal range is 7.35 to 7.45. Any blood pH below 7.35 (7.34, 7.33, 7.32, and so on…) is ACIDOSIS; PaCO2 is 24. The
ACIDOSIS and lines up with HCO3 which is METABOLIC. Therefore, this group of ABG values is considered METABOLIC
ACIDOSIS; Lastly, it is PARTIALLY COMPENSATED because all three (3) values are abnormal. It is considered partially
compensated if all three (3) values are abnormal.

B. Respiratory Alkalosis, Partially Compensated
RATIONALE: B. Respiratory Alkalosis, Partially Compensated - Based on the given ABG values, pH is 7.64. For pH, the
ALKALOSIS and lines up with PaCO2 which is RESPIRATORY. Therefore, this group of ABG values is considered
RESPIRATORY ALKALOSIS; Lastly, it is PARTIALLY COMPENSATED because all three (3) values are abnormal. It is
considered partially compensated if all three (3) values are abnormal.
A. Metabolic Alkalosis, Fully Compensated
B. Respiratory Alkalosis, Fully Compensated
D. Respiratory Acidosis, Partially Compensated
RATIONALE: A. Metabolic Alkalosis, Fully Compensated - Based on the given ABG values, pH is 7.45. For pH, the normal
range is 7.35 to 7.45. So it is NORMAL; PaCO2 is 50. The normal range for PaCO2 is from 35 to 45. If PaCO2 is above 45, it
is acidosis. Based on the given ABG values, PaCO2 is above 45, so it is considered ACIDOSIS; HCO3- is 30. The normal
range for HCO3 is from 22 to 26. If HCO3 is above 26, it is alkalosis. Based on the given ABG values, HCO3 is above 26, so
it is considered ALKALOSIS; For these ABG values, pH is NORMAL but slightly alkalosis and lines up with HCO3 which is
METABOLIC. Therefore, this group of ABG values is considered METABOLIC ALKALOSIS; Lastly, it is FULLY COMPENSATED
because pH is normal. It is considered fully compensated if pH is normal.
A. Metabolic Alkalosis, Partially Compensated

B. Metabolic Alkalosis, Fully Compensated
C. Respiratory Acidosis, Partially Compensated
D. Respiratory Alkalosis, Fully Compensated
RATIONALE: A. Metabolic Alkalosis, Partially Compensated - Based on the given ABG values, pH is 7.6. For pH, the
normal range for PaCO2 is from 35 to 45. If PaCO2 is above 45, it is acidosis. Based on the given ABG values, PaCO2 is
above 45, so it is considered ACIDOSIS; HCO3- is 38. The normal range for HCO3 is from 22 to 26. If HCO3 is above 26, it
is alkalosis. Based on the given ABG values, HCO3 is above 26, so it is considered ALKALOSIS; For these ABG values, pH is
ALKALOSIS and lines up with HCO3 which is METABOLIC. Therefore, this group of ABG values is considered METABOLIC
ALKALOSIS; Lastly, it is PARTIALLY COMPENSATED because all three (3) values are abnormal. It is considered partially
compensated if all three (3) values are abnormal.
A. Respiratory Alkalosis, Partially Compensated

B. Metabolic Alkalosis, Partially Compensated
C. Respiratory Acidosis, Uncompensated
D. Respiratory Alkalosis, Uncompensated
RATIONALE: D. Respiratory Alkalosis, Uncompensated - Based on the given ABG values, pH is 7.5. For pH, the normal
range is 7.35 to 7.45. Any blood pH above 7.45 (7.46, 7.47, 7.48, and so on…) is ALKALOSIS; PaCO2 is 19. The normal
range for PaCO2 is from 35 to 45. If PaCO2 is below 35, it is alkalosis. Based on the given ABG values, PaCO2 is below 35,
so it is considered ALKALOSIS; HCO3- is 22. The normal range for HCO3 is from 22 to 26. It is NORMAL; For these ABG
values, pH is ALKALOSIS and lines up with PaCO2 which is RESPIRATORY. Therefore, this group of ABG values is
considered RESPIRATORY ALKALOSIS; Lastly, it is UNCOMPENSATED because HCO3 is normal and PaCO2 is abnormal. It is
uncompensated if PaCO2 or HCO3 is normal and the other is abnormal.

B. Metabolic Alkalosis, Uncompensated
C. Respiratory Acidosis, Fully Compensated
RATIONALE: C. Respiratory Acidosis, Fully Compensated - Based on the given ABG values, pH is 7.39. For pH, the normal
range is 7.35 to 7.45. So it is NORMAL; PaCO2 is 59. The normal range for PaCO2 is from 35 to 45. If PaCO2 is above 45, it
is acidosis. Based on the given ABG values, PaCO2 is above 45, so it is considered ACIDOSIS; HCO3- is 35. The normal
range for HCO3 is from 22 to 26. If HCO3 is above 26, it is alkalosis. Based on the given ABG values, HCO3 is above 26, so
it is considered ALKALOSIS; For these ABG values, pH is NORMAL but slightly acidic and lines up with PACO2 which is
RESPIRATORY. Therefore, this group of ABG values is considered RESPIRATORY ACIDOSIS; Lastly, it is FULLY
COMPENSATED because pH is normal. It is considered fully compensated if pH is normal.

C. Delay Hanging The Blood and Notify The HCP

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C. Delay Hanging The Blood and Notify The HCP

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1. Packed red blood cells have been prescribed for a client with low hemoglobin and hematocrit levels.

The nurse takes

a. Begin the transfusion as prescribed

a. "Have you ever had a transfusion before?"

a. Remove the IV line

a. Increased hematocrit level

a. Maintain bed rest with legs elevated

a. To treat the loss of platelets

a. Ask a family member to donate blood ahead of time

a. Begin the transfusion as prescribed

a. The right route

a. to treat the loss of platelets

a. "have you ever had a transfusion before?"

a. Increased hematocrit level

RATIONALE: C. Diphenhydramine (Benadryl) - An urticarial reaction is characterized by a rash accompanied by pruritus.

a. give an autologous blood donation before the surgery

a. Warming the blood prior transfusion.

a. Intake and output.

a. Provide clotting factors and volume expansion.

a. Run a solution of 5% dextrose in water.

a. Less frequent febrile episodes.

a. Give an antipyretic and begin the transfusion.

25. When to transfuse?: When Hgb is below 7 or they are symptomatic

A. Hemoglobin level 7 g/dL

4. What blood type is known as the “universal donor”?

RATIONALE: The answer is D. Type O is known as the universal donor.

RATIONALE: The answer is C. Type AB is known as the universal recipient.

A. A patient with O- blood.

RATIONALE: The answer is C. The blood must be started within 30 minutes.

A. 15 minutes before starting the transfusion

A. PVC free tubing and dextrose

A. Administer the blood transfusion as ordered.

A. Stop the transfusion

RATIONALE: The answer is A. Only NORMAL SALINE is compatible with blood.

A. Febrile transfusion reaction

A. Notify the physician.

A. Facilitating blood coagulation

A. Complete the infusion over 6 hours.

A. Discard the blood bag and tubing.

A. Infuse the blood component with no filter in the line.

A. Squeeze the filter.

9. Why are infusions of blood products started slowly?

A. A slow start allows adequate time for platelets to thaw.

a. Metabolic Acidosis, compensated

a. A decreased pH and an increased CO2

**(Base/Bicarbonate is lost through an ileostomy)

a. Respirations that cease for several seconds

a. Metabolic Acidosis with compensation

a. pH 7.25, Pco2 50,

a. Sodium level of 145

Select all the apply:

A. Respiratory Acidosis, Uncompensated

A. Respiratory Acidosis, Uncompensated

A. Respiratory Alkalosis, Uncompensated

A. Respiratory Alkalosis, Partially Compensated

A. Respiratory Alkalosis, Fully Compensated

A. Metabolic Acidosis, Uncompensated

A. Metabolic Acidosis, Uncompensated

A. Respiratory Acidosis, Uncompensated

RATIONALE: B. 36 mm Hg - The normal range for PaCO2 is from 35 to 45 mm Hg.

A. Both will be lower than normal.

A. Kidneys and Lungs

7. The major effect of acidosis is overexcitement of the central nervous system.