NCLEX Hematology & Transfusion questions
The PrepScore bank has 77 Hematology & Transfusion questions, each with a rationale and two tags: the Client Needs category from the test plan and the clinical judgment step it tests. In this topic the items lean on Take action and Analyze cues, which is worth knowing before you practise it. Three worked samples are below, answers behind a reveal.
Iron/B12/folate anemias, sickle cell crisis, hemophilia, ITP, DIC, transfusion reactions, multiple myeloma, anticoagulant teaching (warfarin/heparin/DOAC), neutropenic vs thrombocytopenic precautions, heme multi-patient priority.
Three worked questions
Q1. The transfusion nurse evaluates for TACO (transfusion-associated circulatory overload). Which findings SUGGEST TACO? Select all that apply.
- A. Dyspnea + orthopnea + tachypnea during/within 6 hours of transfusion
- B. Hypoxemia + bilateral pulmonary infiltrates (volume overload pattern)
- C. Elevated BP + JVD + S3 gallop + bibasilar crackles
- D. Elevated BNP/NT-proBNP supports diagnosis (volume overload)
- E. Risk factors: elderly, HF, CKD, rapid transfusion, multiple units, positive fluid balance
- F. Fever and rash within minutes of transfusion (NOT TACO — features of febrile reaction or allergic, not volume overload)
Show answer and rationale
Answer: Dyspnea + orthopnea + tachypnea during/within 6 hours of transfusionHypoxemia + bilateral pulmonary infiltrates (volume overload pattern)Elevated BP + JVD + S3 gallop + bibasilar cracklesElevated BNP/NT-proBNP supports diagnosis (volume overload)Risk factors: elderly, HF, CKD, rapid transfusion, multiple units, positive fluid balance
TACO: volume overload during/within 6 h of transfusion. Dyspnea + JVD + crackles + elevated BP + BNP + risk factors. Not febrile/allergic.
Q2. The transfusion nurse evaluates a possible TACO. Which findings SUGGEST TACO? Select all that apply.
- A. Dyspnea + orthopnea + tachypnea during/within 6 hours of transfusion
- B. Hypoxemia + bilateral pulmonary infiltrates (volume overload pattern)
- C. Elevated BP + JVD + S3 + crackles + peripheral edema
- D. Elevated BNP/NT-proBNP
- E. Risk factors: elderly, HF, CKD, rapid transfusion, multiple units, positive fluid balance
- F. Hypotension without congestion (NOT TACO — TACO has volume overload features)
Show answer and rationale
Answer: Dyspnea + orthopnea + tachypnea during/within 6 hours of transfusionHypoxemia + bilateral pulmonary infiltrates (volume overload pattern)Elevated BP + JVD + S3 + crackles + peripheral edemaElevated BNP/NT-proBNPRisk factors: elderly, HF, CKD, rapid transfusion, multiple units, positive fluid balance
TACO: volume overload + within 6 h of transfusion. Dyspnea + congestion + BNP + risk factors. Hypotension without congestion would suggest different reaction.
Q3. The transfusion nurse evaluates for AHTR. Which features SUPPORT acute hemolytic transfusion reaction? Select all that apply.
- A. Fever + chills during/within hours of transfusion
- B. Back/flank pain + abdominal pain + chest pain
- C. Hypotension + tachycardia + shock
- D. Hemoglobinuria (dark/red urine) from intravascular hemolysis
- E. Oliguria + AKI from acute tubular necrosis; DIC; hyperK
- F. Stable vitals + no symptoms after large transfusion (NOT — AHTR has reaction features)
Show answer and rationale
Answer: Fever + chills during/within hours of transfusionBack/flank pain + abdominal pain + chest painHypotension + tachycardia + shockHemoglobinuria (dark/red urine) from intravascular hemolysisOliguria + AKI from acute tubular necrosis; DIC; hyperK
AHTR: fever + chills + back/flank pain + hypotension + hemoglobinuria + oliguria + AKI + DIC + hyperK. Stable without symptoms is not AHTR.
The rules that decide these questions
From the pack's rule cards — the reasoning shortcuts a wrong answer usually means you were missing.
Iron deficiency: MICROCYTIC (MCV < 80) + low ferritin + high TIBC; common from chronic blood loss. Take oral iron on EMPTY stomach with VITAMIN C; AVOID dairy/calcium/antacids/coffee/tea within 1 hr. Dark stools expected. B12 deficiency: MACROCYTIC + neuro symptoms (paresthesia, ataxia); pernicious anemia → IM B12 lifelong. Folate deficiency: MACROCYTIC, no neuro symptoms. Investigate source of loss in IDA.
VOC triggers: dehydration, infection, hypoxia, cold, stress, acidosis. Treatment: IV fluids (1.5x maintenance per protocol) + O2 to SpO2 ≥ 95 + IV opioid (scheduled/PCA, not PRN-only; sickle pain is severe + real — undertreat = pseudoaddiction) + WARM compresses + treat infection. AVOID cold (vasoconstriction worsens sickling). Watch for acute chest syndrome (chest pain + fever + hypoxia + new infiltrate). Hydroxyurea prevents future crises.
Hemophilia A = factor VIII deficiency (X-linked); Hemophilia B = factor IX. PT normal, aPTT prolonged. Hemarthrosis = swollen warm tense joint after minor trauma. Acute bleed: factor concentrate IMMEDIATELY before other interventions, then RICE. Pain: acetaminophen + opioid; NEVER NSAIDs/aspirin (platelet inhibition). Avoid IM, rectal temps, contact sports. Life-threatening bleeds (head/airway/GI) = high-dose factor + imaging.
Isolated thrombocytopenia + post-viral + mucocutaneous bleeding. Treat with corticosteroids (1st line) or IVIG (rapid). AVOID routine platelet transfusion — autoantibodies destroy transfused platelets; reserve for life-threatening bleed. Bleeding precautions: soft toothbrush + electric razor + no NSAIDs/aspirin + no IM + pressure 5-10 min post needles + prevent constipation. Report severe headache (ICH), GI bleed, hematuria.
Simultaneous bleeding + clotting: ↓ platelets, ↑ PT/PTT, ↓ fibrinogen, ↑↑ D-dimer + FDPs. Triggers: sepsis, trauma, malignancy, obstetric. Treatment: TREAT UNDERLYING CAUSE + supportive — FFP for PT/PTT prolongation, cryoprecipitate for fibrinogen < 100-150, platelets for active bleeding + count < 50, RBC as needed. Heparin only in select thrombotic-predominant DIC; NOT in bleeding-predominant.
Acute hemolytic reaction signs (first 15 min): fever + chills + back/flank pain + dark urine + hypotension + tachycardia. ACTION: STOP transfusion IMMEDIATELY → disconnect tubing → start NEW NS via NEW tubing (don't flush old line into patient) → notify provider + blood bank → send bag + tubing back → labs (DAT, haptoglobin, LDH, BUN/Cr, urine for Hb) → maintain BP + UO > 1 mL/kg/hr. Differentiate febrile non-hemolytic (mild fever only) vs anaphylactic vs TRALI vs TACO.
Practise the whole pack, tagged and explained
Every item carries its Client Needs category and clinical judgment step, so a wrong answer names the step that failed.
Frequently asked questions
How many Hematology & Transfusion questions does the bank have?
77 multiple-choice items, plus 10 unfolding cases in the Hematology & Transfusion pack, each with a rationale.
Are the samples real bank items?
Yes — the three questions above are drawn from the live bank, with their real rationales and tags.
Which clinical judgment steps does this topic train?
Most items in this topic test Take action and Analyze cues, though every step appears.
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