ATI RN
Burns Pediatric Primary Care 7th Edition Test Bank Questions
Question 1 of 5
A client is receiving a blood transfusion. If this client experiences an acute hemolytic reaction, which nursing intervention is the most important?
Correct Answer: D
Rationale: In the case of an acute hemolytic reaction during a blood transfusion, the most important nursing intervention is to immediately stop the transfusion and infuse normal saline solution. This is crucial to prevent further complications associated with the hemolysis of red blood cells. Normal saline helps maintain blood pressure and support kidney function, which may be compromised during a hemolytic reaction. Additionally, notifying the blood bank is important to investigate and prevent future reactions, and to determine if there was an error in blood compatibility. Administering antihistamines or changing the fluid type (such as dextrose 5% in water) will not address the underlying issue of hemolysis and may not be the most appropriate interventions in this scenario.
Question 2 of 5
You would not find which of the following assessments in a patient with severe anemia?
Correct Answer: C
Rationale: Severe anemia is associated with a reduced number of red blood cells, leading to decreased oxygen delivery to the body's tissues. Therefore, symptoms commonly seen in patients with severe anemia include pallor (pale skin), fatigue (due to decreased energy levels), and dyspnea (shortness of breath) especially on exertion (due to the heart working harder to compensate for the reduced oxygen-carrying capacity of the blood). Cold sensitivity is not a typical symptom of anemia and is not directly related to the reduced oxygen-carrying capacity of the blood.
Question 3 of 5
A 50-year-old African American patient is diagnosed with anemia. Where can the nurse assess for pallor?
Correct Answer: D
Rationale: When assessing for pallor in a patient with anemia, the nurse should specifically look at the conjunctivae (the membranes that cover the white part of the eyes). In individuals with anemia, the lack of red blood cells can result in paleness in the conjunctivae, which can be observed as a pale or whitish color. This area is especially useful for assessing pallor in individuals with darker skin tones, such as African Americans, where pallor may be less noticeable on other areas of the body.
Question 4 of 5
For a client with polycythemia vera, how can the nurse help decrease the risk for thrombus formation?
Correct Answer: B
Rationale: For a client with polycythemia vera, there is an increased risk for thrombus formation due to the increased viscosity of the blood. Wearing thromboembolic stockings or support hose can help promote circulation, prevent stasis, and reduce the risk of thrombus formation. Compression stockings provide external pressure to the legs, which helps prevent blood from pooling and clotting. This intervention is commonly recommended for patients at risk for thrombus formation to improve blood flow in the lower extremities and reduce the risk of deep vein thrombosis (DVT) and pulmonary embolism.
Question 5 of 5
An adult is diagnosed with disseminated intravascular coagulation. The nurse should identify that the client is at risk for which of the following nursing diagnosis?
Correct Answer: C
Rationale: Disseminated intravascular coagulation (DIC) is a serious condition that involves widespread activation of coagulation leading to microthrombi formation in blood vessels throughout the body. This process can lead to consumption of clotting factors and platelets, causing both bleeding and thrombosis. In the context of DIC, there is a risk for altered tissue perfusion due to the combination of bleeding and microthrombi formation, which can impair blood flow to vital organs and tissues. This condition can ultimately result in organ dysfunction and failure, making it a significant concern in the care of a client with DIC. Therefore, the correct nursing diagnosis for a client with DIC is alteration in tissue perfusion related to bleeding and diminished blood flow.