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When assessing a patient with a brain injury- using the Glasgow Coma Scale (GCS), the nurse gathers information regarding which of the following parameters?

Level of consciousness

Reflex activity

Sensory involvement

Cognitive ability

Answer and Explanation

The Correct Answer is A

A. Correct. The GCS assesses level of consciousness based on eye-opening, verbal response, and motor response.

B. Incorrect. Reflex activity is assessed separately using neurological reflex tests.

C. Incorrect. Sensory involvement is evaluated through different neurological exams, not the GCS.

D. Incorrect. Cognitive ability assessment requires specialized tests, such as the Mini-Mental State Examination (MMSE).

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Correct Answer is C

Explanation

A. Hct 45%. – Normal range for hematocrit (Hct) is 38-50%. No need to report.

B. Hgb 14.7 g/dL. – Normal range for hemoglobin (Hgb) is 13-17 g/dL. No need to report.

C. WBC 1,700/mm³. – Correct Answer. Normal WBC count is 4,000-11,000/mm³. A WBC count of 1,700/mm³ (neutropenia) places the patient at high risk for infection, requiring immediate intervention.

D. Platelets 160,000/mm³. – Normal range for platelets is 150,000-450,000/mm³. No need to report.

A. Allergic B. Hemolytic C. Acute pain D. Febrile

Correct Answer is B

Explanation

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

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

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

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

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When assessing a patient with a brain injury- using the Glasgow Coma Scale (GCS), the nurse gathers information regarding which of the following parameters?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reviewing a patient's laboratory values. Which of the following values should the nurse report to the provider?

Correct Answer is C

Explanation

A nurse is caring for a patient who is receiving a unit of packed red blood cells. Fifteen minutes following the start of the transfusion, the nurse notes that the patient is febrile, with chills and red-tinged urine. Which of the following transfusion reactions should the nurse suspect?

Correct Answer is B

Explanation

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