ATI RN
ATI 410 Med Surg Exam Questions
Extract:
Question 1 of 5
A nurse is caring for a client who is receiving a unit of packed red blood cells. Fifteen minutes following the start of the transfusion, the nurse notes that the client is febrile, with chills and red-tinged urine. Which of the following transfusion reactions should the nurse suspect?
Correct Answer: D
Rationale: A hemolytic reaction involves red blood cell destruction, leading to fever, chills, and red-tinged urine due to hemoglobin in the urine, indicating a serious reaction.
Question 2 of 5
A nurse is caring for a client who has a prescription for one unit of packed RBCs. The nurse should plan to remain in the room with the client at which of the following times during the infusion to observe for a transfusion reaction?
Correct Answer: D
Rationale: Transfusion reactions typically occur within the first 15 minutes of starting the blood transfusion. The nurse should remain with the patient during this critical period to monitor for signs of a reaction, such as fever, chills, rash, or difficulty breathing.
Question 3 of 5
A nurse remains with a client to observe for any adverse reactions after initiating a transfusion of packed RBCs. The client becomes apprehensive and tachycardic, reporting headache and low back pain. The nurse should recognize that these findings indicate which of the following transfusion reactions?
Correct Answer: A
Rationale: Acute hemolytic reactions present with fever, chills, headache, low back pain, tachycardia, and apprehension due to red blood cell destruction, requiring immediate intervention.
Question 4 of 5
A nurse is monitoring a client who reports having chills and back pain during a blood transfusion. Which of the following actions is the nurse's priority?
Correct Answer: B
Rationale: Chills and back pain suggest a serious transfusion reaction, like hemolytic reaction. Stopping the transfusion immediately is the priority to prevent further complications.
Question 5 of 5
A nurse is providing teaching to a client who has neutropenia. Which of the following information should the nurse include in the teaching?
Correct Answer: A
Rationale: Neutropenic patients are highly susceptible to infections. Crowded places increase the risk of exposure to pathogens. Fresh fruits and vegetables can harbor bacteria, posing a risk for infection in neutropenic individuals. Neutropenic patients should monitor their temperature daily, not weekly, to detect infections early. Gardening can expose individuals to soil-borne organisms that could lead to infections.