A nurse is administering a blood transfusion to a client and suspects that the client is having an adverse reaction to the blood. Which of the following actions should the nurse take first?

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PN ATI Capstone Adult Medical-Surgical 1 Quiz Questions

Question 1 of 5

A nurse is administering a blood transfusion to a client and suspects that the client is having an adverse reaction to the blood. Which of the following actions should the nurse take first?

Correct Answer: D

Rationale: The correct answer is to stop the transfusion. When a nurse suspects an adverse reaction to a blood transfusion, the priority is to stop the infusion immediately to prevent further harm to the client. Maintaining IV access and obtaining vital signs can be important steps but should come after stopping the transfusion to ensure the client's safety. Contacting the provider is necessary but not the first action to take in this situation. Therefore, the nurse should prioritize stopping the transfusion to address the potential adverse reaction.

Question 2 of 5

A nurse is caring for a client who has chronic kidney disease. Which of the following diets should the nurse anticipate the provider to prescribe?

Correct Answer: B

Rationale: Clients with chronic kidney disease often have difficulty regulating potassium levels in their blood. A potassium-restricted diet helps prevent hyperkalemia, a common complication in these clients. High sodium diet (Choice A) is typically avoided in kidney disease to prevent fluid retention and high blood pressure. High phosphorus diet (Choice C) is usually restricted in kidney disease as elevated phosphorus levels can lead to bone and heart problems. While protein is important for overall health, a high protein diet (Choice D) can put extra strain on the kidneys and is usually limited in chronic kidney disease.

Question 3 of 5

A nurse is assessing a client who reports a possible exposure to HIV. Which of the following findings should the nurse identify as an early manifestation of HIV infection?

Correct Answer: B

Rationale: The correct answer is B: Fatigue. A client with early HIV infection can be asymptomatic or experience symptoms like viral infections, such as fever, rash, and fatigue. Fatigue is a common early manifestation of HIV infection due to the body's immune response. Stomatitis (choice A) is more commonly associated with oral health issues or infections. Wasting syndrome (choice C) and lipodystrophy (choice D) are more advanced manifestations seen in later stages of HIV infection, characterized by severe weight loss and changes in body fat distribution, respectively.

Question 4 of 5

A nurse is providing dietary teaching for a client who has chronic cholecystitis. Which of the following diets should the nurse recommend?

Correct Answer: C

Rationale: The correct answer is C: 'Low fat diet.' A client with chronic cholecystitis should follow a low-fat diet to decrease the frequency of biliary colic episodes. Fats can trigger the release of cholecystokinin, which stimulates the gallbladder to contract, potentially causing pain in individuals with cholecystitis. Choices A, B, and D are incorrect. A low potassium diet is prescribed for individuals with specific kidney conditions or on certain medications. A high fiber diet is beneficial for conditions like constipation, diverticulosis, or to promote general bowel health. A low sodium diet is often recommended for conditions like hypertension or heart failure to reduce fluid retention.

Question 5 of 5

A nurse is teaching a client about using a continuous positive airway pressure (CPAP) device to treat obstructive sleep apnea. Which of the following information should the nurse include in the teaching?

Correct Answer: C

Rationale: The correct information that the nurse should include in the teaching about a CPAP device is that it delivers a preset amount of airway pressure throughout the breathing cycle. This consistent positive airway pressure helps keep the airway open during both inspiration and expiration. Choice A is incorrect as CPAP does not deliver pressure only at the beginning of each breath. Choice B is incorrect because CPAP provides a constant level of pressure without continuous adjustments throughout the cycle. Choice D is incorrect as CPAP does not provide positive pressure at the end of each breath; instead, it maintains a continuous positive pressure.

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