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?

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ATI RN Custom Exams Set 4 Questions

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?

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 teaching a community class to people with Type 2 diabetes mellitus. Which explanation would explain the development of Type 2 diabetes?

Correct Answer: D

Rationale: The correct answer is D. In Type 2 diabetes, the primary issue is insulin resistance, where cells do not respond effectively to insulin. Choice A is incorrect because in Type 1 diabetes, the islet cells in the pancreas stop producing insulin. Choice B is not directly related to the development of Type 2 diabetes but rather to its management. Choice C is incorrect as it refers to a dysfunction in vasopressin production, which is not related to Type 2 diabetes.

Question 3 of 5

Which risk factor would the nurse expect to find in the client diagnosed with pancreatic cancer?

Correct Answer: C

Rationale: The correct answer is chronic alcoholism. Chronic alcoholism is a significant risk factor for pancreatic cancer due to its impact on the pancreas. Chewing tobacco (choice A) is more associated with oral and throat cancers, not pancreatic cancer. A low-fat diet (choice B) is actually considered a protective factor against pancreatic cancer. Exposure to industrial chemicals (choice D) may be a risk factor for other types of cancer but is not strongly linked to pancreatic cancer.

Question 4 of 5

Which endocrine disorder would the nurse assess for in a client who has a closed head injury with increased intracranial pressure?

Correct Answer: B

Rationale: The correct answer is B, Diabetes insipidus. Diabetes insipidus can develop after a head injury due to damage to the hypothalamus or pituitary gland, leading to a deficiency in antidiuretic hormone (ADH). Pheochromocytoma (choice A) is a tumor of the adrenal gland and is not directly related to closed head injury or increased intracranial pressure. Hashimoto's disease (choice C) is an autoimmune disorder affecting the thyroid gland, not commonly associated with head injuries. Gynecomastia (choice D) is the development of breast tissue in males and is not an endocrine disorder typically linked to closed head injuries.

Question 5 of 5

Which outcome should the nurse identify for the client diagnosed with fluid volume excess?

Correct Answer: C

Rationale: The correct answer is C. Absence of adventitious breath sounds indicates that fluid is not accumulating in the lungs, a key outcome in managing fluid volume excess. Choices A, B, and D are incorrect. A client with fluid volume excess may not necessarily void a minimum of 30 mL per hour, have elastic skin turgor, or have a specific serum creatinine level. The absence of adventitious breath sounds is a more direct indicator of managing fluid volume excess.

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