ATI RN
ADPIE Nursing Process Questions Questions
Question 1 of 5
While monitoring a client for the development of disseminated intravascular coagulation (DIC), the nurse should take note of what assessment parameters?
Correct Answer: A
Rationale: The correct answer is A: Platelet count, prothrombin time, and partial thromboplastin time. These parameters are essential in monitoring DIC because platelet count reflects the risk of bleeding, while prolonged prothrombin time and partial thromboplastin time indicate impaired clotting function, which is characteristic of DIC. Explanation for why other choices are incorrect: - Choice B: Blood glucose levels and WBC count are not specific indicators for DIC monitoring. - Choice C: Thrombin time, calcium levels, and potassium levels do not directly assess clotting abnormalities associated with DIC. - Choice D: While fibrinogen level is important in DIC, WBC count alone is not a specific indicator for monitoring DIC.
Question 2 of 5
A clinical nurse specialist (CNS) is orienting a new graduate registered nurse to an oncology unit where blood product transfusions are frequently administered. In discussing ABO compatibility, the CNS presents several hypothetical scenarios. A well-informed new graduate would know the greatest likelihood of an acute hemolytic reaction would occur when giving:
Correct Answer: A
Rationale: The correct answer is A: A-positive blood to an A-negative client. This is because in ABO blood typing, individuals with blood type A have anti-B antibodies in their plasma. Therefore, if A-positive blood (which contains the A antigen) is given to an A-negative client (who has anti-A antibodies), there is a high risk of an acute hemolytic reaction due to the antibodies attacking the transfused blood cells. Choices B, C, and D are incorrect because they do not involve a mismatch of ABO blood types that would lead to a significant risk of acute hemolytic reaction. In choice B, O-positive blood can be safely transfused to an A-positive client as O blood is considered the universal donor. In choice C, O-negative blood can be safely given to an O-positive client as O-negative blood is compatible with all blood types. In choice D, B-positive blood can be safely administered to an AB-positive client as the AB blood type can receive both
Question 3 of 5
When taking the blood pressure of a client who has AIDS the nurse must;
Correct Answer: B
Rationale: The correct answer is B: Use barrier techniques. When taking the blood pressure of a client with AIDS, using barrier techniques such as gloves and disposable equipment is crucial to prevent the transmission of the virus through blood or bodily fluids. Wearing a mask and gown (choice A) may not be necessary unless there is a risk of splashes or sprays. Washing hands thoroughly (choice C) is important, but alone may not provide sufficient protection. Choice D is incomplete.
Question 4 of 5
A patient admitted with gastrointestinal tract bleeding has a hemoglobin level of 6 g/dL. She asks the nurse why she feels SOB. Which response is best?
Correct Answer: B
Rationale: The correct answer is B because hemoglobin carries oxygen to the tissues, and with a low hemoglobin level of 6 g/dL, there is insufficient oxygen-carrying capacity to meet the body's needs, leading to shortness of breath (SOB). Choice A is incorrect as anemia affects oxygen transport, not absorption. Choice C is incorrect as anemia affects oxygen delivery, not nutrient delivery. Choice D is incorrect as the primary reason for SOB in this scenario is the lack of oxygen-carrying capacity due to low hemoglobin levels, not lung damage from blood loss.
Question 5 of 5
What are the nursing interventions for a client with thalassemia?
Correct Answer: A
Rationale: The correct answer is A because thalassemia is a genetic blood disorder that can cause anemia and fatigue. By maintaining the client on bed rest and protecting them from infections, we can help prevent complications such as fatigue and infections due to reduced red blood cell production. Ambulating the client frequently (choice B) may lead to increased fatigue and risk of injury. Advising to drink 3 quarts of fluid per day (choice C) is not specific to thalassemia treatment and could potentially worsen symptoms. Instructing the client to elevate lower extremities (choice D) is not directly related to managing thalassemia and may not provide significant benefits in this context.