ATI RN
ATI N120n122 Med Surg Exam Questions
Question 1 of 5
A nurse is preparing to transfuse a unit of packed red blood cells for a client with severe anemia. The nurse should identify that which of the following interventions will help prevent an acute hemolytic reaction?
Correct Answer: A
Rationale: Ensuring the blood is compatible with the client's blood type is critical in preventing an acute hemolytic reaction, as incompatible blood transfusions can cause serious, potentially life-threatening reactions. Administering the transfusion rapidly can increase the risk of complications and does not prevent hemolytic reactions; transfusions should be given at a safe rate based on the client's condition. Using a blood warmer is not a standard intervention to prevent hemolytic reactions; it's typically used in specific cases such as massive transfusions or hypothermia, but it does not address compatibility. Administering prophylactic antihistamines is not a recommended practice to prevent hemolytic reactions; it is more relevant for preventing allergic reactions associated with transfusions.
Question 2 of 5
A nurse is caring for a client with acquired immunodeficiency syndrome (AIDS). The nurse notes white lesions on the client's tongue. What opportunistic infection is this client experiencing?
Correct Answer: A
Rationale: Candidiasis, commonly known as thrush, is characterized by white lesions on the tongue and is a common opportunistic infection in clients with AIDS due to their compromised immune system. Xerostomia refers to dry mouth and does not cause white lesions; it can occur in various conditions but is not an opportunistic infection. Halitosis is bad breath and does not correlate with white lesions on the tongue; it can result from various causes but is not an infection. Gingivitis involves inflammation of the gums and may present with red, swollen gums but does not typically cause white lesions on the tongue.
Question 3 of 5
A nurse is planning care for a client with pernicious anemia. Which intervention should the nurse plan to implement?
Correct Answer: D
Rationale: Vitamin B injections are the correct intervention for pernicious anemia because the condition results from an inability to absorb vitamin B12 due to a lack of intrinsic factor, making injections necessary to restore vitamin levels. Blood transfusions are not a primary treatment for pernicious anemia; they may be used in severe cases but do not address the underlying cause of the condition, which is vitamin B12 deficiency. Daily hydroxyurea is primarily used to treat certain types of cancer and sickle cell disease, not pernicious anemia. Iron supplements are not effective in treating pernicious anemia, as the condition is due to a deficiency of vitamin B12, not iron.
Question 4 of 5
A nurse is monitoring a client receiving a blood transfusion. Which of the following findings indicates an allergic transfusion reaction?
Correct Answer: B
Rationale: Generalized urticaria, or hives, is a classic sign of an allergic transfusion reaction, presenting as an itchy rash or welts on the skin. Distended jugular veins may indicate fluid overload or congestive heart failure, not an allergic reaction. Bilateral flank pain is more indicative of a hemolytic reaction, particularly due to kidney involvement, rather than an allergic reaction. A blood pressure of 184/92 mm Hg may suggest hypertension or a reaction, but it is not specific to allergic transfusion reactions, which are characterized by skin symptoms like urticaria.
Question 5 of 5
A nurse is administering a unit of RBC 350 mL over 3 hr to a client who has anemia. The nurse should set the IV pump to deliver how many mL/hr? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)
Correct Answer: 117
Rationale: Infusion rate (mL/hr) = Volume to be infused (mL) / Time (hr). In this case: Volume to be infused = 350 mL, Time = 3 hours. Plugging the values into the formula: Infusion rate = 350 mL / 3 hours = 116.67 mL/hr. Rounding to the nearest whole number, the infusion rate is 117 mL/hr.