ATI RN
Anatomy of Hematologic System Questions
Question 1 of 5
The nurse is monitoring a patient receiving a blood product and is concerned that the blood is going to deteriorate before it is complete infused. What is the maximum time that blood can hang during infusion before it begins to deteriorate?
Correct Answer: D
Rationale: The correct answer is D: 4 hours. Blood products typically have a maximum hang time of 4 hours to prevent bacterial contamination and ensure the integrity of the product. Beyond 4 hours, the risk of bacterial growth and contamination increases, leading to potential harm for the patient. Therefore, it is crucial to adhere to this time limit to maintain the safety and effectiveness of the blood product. Summary: - A (1 hour), B (2 hours), and C (3 hours) are incorrect because they do not align with the standard maximum hang time for blood products, which is 4 hours. Adhering to this time limit is essential to prevent deterioration and ensure patient safety.
Question 2 of 5
The nurse is assisting with the preparation of a blood transfusion for a patient. Which type of fluid should the nurse select to transfuse with the blood?
Correct Answer: A
Rationale: Rationale: A 0.9% normal saline solution is the correct choice for blood transfusion because it is isotonic, which closely matches the osmolarity of blood. This helps prevent hemolysis and maintains the integrity of red blood cells during transfusion. Other choices such as B (dextrose 5% and water), C (dextrose 5% and 0.9% normal saline), and D (dextrose 5% and 0.45% normal saline) are incorrect because they do not provide the necessary isotonic environment for safe blood transfusion, risking hemolysis or other complications.
Question 3 of 5
A nurse reviews the laboratory data for an older patient. The nurse would be most concerned about which finding?
Correct Answer: D
Rationale: The correct answer is D because a low WBC count of 2800/L indicates leukopenia, which can compromise the immune system in older adults, leading to increased susceptibility to infections. This finding is concerning as it can pose serious health risks. A: A hematocrit of 35% is within the normal range for older adults and not a cause for concern. B: A hemoglobin level of 11.8 g/dL is slightly lower but still within an acceptable range for older adults and unlikely to be a major concern. C: A platelet count of 400000/L is within the normal range and would not be a significant worry for the nurse. In summary, a low WBC count can indicate a weakened immune system, making it the most concerning finding among the choices given.
Question 4 of 5
The nurse examines the lymph nodes of a patient during a physical assessment. Which assessment finding would be of most concern to the nurse?
Correct Answer: A
Rationale: The correct answer is A: A 2-cm nontender supraclavicular node. This finding is concerning because supraclavicular nodes are not normally palpable. Enlarged supraclavicular nodes can indicate metastatic cancer. B is incorrect because mobile and nontender axillary nodes are usually benign. C is incorrect as the inability to palpate superficial nodes may be normal. D is incorrect as firm inguinal nodes could indicate a localized infection or inflammation.
Question 5 of 5
A client is having a bone marrow biopsy today. What action by the nurse takes priority?
Correct Answer: B
Rationale: The correct answer is B: Ensure valid consent is on the chart. This is the priority because obtaining informed consent is crucial before any invasive procedure like a bone marrow biopsy. Without valid consent, the procedure cannot proceed legally or ethically. Administering pain medication (choice A) and premedicating with sedatives (choice D) are important for client comfort but are not the priority. Having the client shower in the morning (choice C) is not directly related to the immediate safety or success of the biopsy.