ATI RN Custom Exams Set 4

Question 1 of 5

The client diagnosed with thalassemia, a hereditary anemia, is to receive a transfusion of packed RBCs. The cross-match reveals the presence of antibodies that cannot be cross-matched. Which precaution should the nurse implement when initiating the transfusion?

A. Start the transfusion at 10-15 mL per hour for 15-30 minutes B. Re-crossmatch the blood until the antibodies are identified C. Have the client sign a permit to receive uncrossmatched blood D. Have the unlicensed nursing assistant stay with the client

Correct Answer: A

Rationale: Starting the transfusion slowly at 10-15 mL per hour for 15-30 minutes is essential when the cross-match reveals the presence of antibodies that cannot be cross-matched. This precaution allows the nurse to monitor for any adverse reactions due to the antibodies. Re-crossmatching the blood until the antibodies are identified (choice
B) may delay the transfusion process and put the client at risk. Having the client sign a permit to receive uncrossmatched blood (choice
C) is not a standard practice and does not address the immediate need for precautions during transfusion. Having the unlicensed nursing assistant stay with the client (choice
D) is unrelated to the safe initiation of the transfusion and is not a precaution specific to managing antibodies in blood products.

Question 2 of 5

The nurse is caring for a client recovering from intestinal surgery. Which assessment finding would require immediate intervention?

A. Presence of thin pink drainage in the Jackson Pratt drain B. Guarding when the nurse touches the abdomen C. Tenderness around the surgical site during palpation D. Complaints of chills and feeling feverish

Correct Answer: D

Rationale: Complaints of chills and feeling feverish may indicate infection, which requires immediate intervention. In this postoperative setting, the presence of thin pink drainage in the Jackson Pratt drain is expected as part of the normal healing process. Guarding when the nurse touches the abdomen and tenderness around the surgical site are common after surgery and may not require immediate intervention unless they are severe or accompanied by other concerning symptoms.

Question 3 of 5

The nurse on the postsurgical unit received a client who was transferred from the post-anesthesia care unit (PACU) and is planning care for this client. The nurse understands that staff should begin planning for this client's discharge at which point during the hospitalization?

A. Is admitted to the surgical unit B. Is transferred from the PACU to the postsurgical unit C. Is able to perform activities of daily living independently D. Has been assessed by the healthcare provider for the first time after surgery

Correct Answer: A

Rationale: Discharge planning should begin as soon as the patient is admitted to the surgical unit to ensure a smooth transition. It is important to start early to address any potential barriers to discharge, coordinate resources, and provide adequate education and support.

Choices B, C, and D are not the appropriate points to start discharge planning as they do not mark the beginning of the hospitalization phase related to the surgical unit.

Question 4 of 5

The nurse is caring for a client who goes into ventricular tachycardia. Which intervention should the nurse implement first?

A. Call a code immediately B. Assess the client for a pulse C. Begin chest compressions D. Continue to monitor the client

Correct Answer: B

Rationale: The correct answer is to assess the client for a pulse. In ventricular tachycardia, the priority is to determine if the client has a pulse. If there is no pulse, immediate initiation of CPR with chest compressions is required. Calling a code or continuing to monitor the client can delay life-saving interventions.
Therefore, assessing for a pulse is the most crucial step in managing ventricular tachycardia.

Question 5 of 5

The client is four hours post-operative abdominal aortic aneurysm repair. Which nursing intervention should be implemented for this client?

A. Assist the client in ambulating B. Assess the client's bilateral pedal pulses C. Maintain a continuous IV heparin drip D. Provide clear liquids to the client

Correct Answer: B

Rationale: Assessing the client's bilateral pedal pulses is crucial at this point to monitor the perfusion to the lower extremities after abdominal aortic aneurysm repair surgery. Ambulation (
Choice
A) may be appropriate but should be guided by the assessment findings. Maintaining a continuous IV heparin drip (
Choice
C) is not typically indicated post-operatively for this type of surgery. Providing clear liquids (
Choice
D) may not be suitable immediately after the surgery, as the client needs time to recover before resuming oral intake.

Nurselytic

ATI RN

ATI RN