ATI RN
ATI N120n122 Med Surg Exam Questions
Extract:
Question 1 of 5
A nurse is monitoring a client receiving a blood transfusion. Which of the following findings indicates an allergic transfusion reaction?
Correct Answer: B
Rationale: Generalized urticaria, or hives, is a classic sign of an allergic transfusion reaction, presenting as an itchy rash or welts on the skin. Distended jugular veins may indicate fluid overload or congestive heart failure, not an allergic reaction. Bilateral flank pain is more indicative of a hemolytic reaction, particularly due to kidney involvement, rather than an allergic reaction. A blood pressure of 184/92 mm Hg may suggest hypertension or a reaction, but it is not specific to allergic transfusion reactions, which are characterized by skin symptoms like urticaria.
Question 2 of 5
A nurse is planning care for a client with pernicious anemia. Which intervention should the nurse plan to implement?
Correct Answer: D
Rationale: Vitamin B injections are the correct intervention for pernicious anemia because the condition results from an inability to absorb vitamin B12 due to a lack of intrinsic factor, making injections necessary to restore vitamin levels. Blood transfusions are not a primary treatment for pernicious anemia; they may be used in severe cases but do not address the underlying cause of the condition, which is vitamin B12 deficiency. Daily hydroxyurea is primarily used to treat certain types of cancer and sickle cell disease, not pernicious anemia. Iron supplements are not effective in treating pernicious anemia, as the condition is due to a deficiency of vitamin B12, not iron.
Question 3 of 5
Which nursing interventions are appropriate for a nurse administering a blood transfusion? Select All That Apply
Correct Answer: B,C,D,E,F
Rationale: Verifying the client's name and blood type with a second nurse is a critical safety measure to prevent transfusion reactions. Infusing the unit of blood within 4 hours is essential to reduce the risk of bacterial growth. Obtaining baseline vital signs prior to starting the transfusion is important to assess the client's condition. Continuously monitoring the client during the first 15 minutes is vital for detecting any signs of a transfusion reaction. Inserting an 18-gauge intravenous catheter is recommended for blood transfusions. Hanging a bag of D5%NS is incorrect; only normal saline should be used. A 22-gauge catheter is acceptable but not preferred.
Question 4 of 5
A nurse is caring for a client with HIV. Which laboratory test would be used to assess the effectiveness of therapy?
Correct Answer: A
Rationale: Viral load count is the primary test used to assess the effectiveness of HIV therapy by measuring the amount of HIV RNA in the blood, indicating how well the treatment is controlling the virus. The Western blot is used as a confirmatory test for HIV diagnosis rather than monitoring therapy effectiveness. The Enzyme immunoassay (EI
A) test is used for initial HIV screening but does not measure viral load or therapy effectiveness. Platelet count can be affected in HIV infection, especially with advanced disease, but it does not directly measure the effectiveness of HIV therapy.
Question 5 of 5
A nurse is caring for a client who has chronic renal disease and is taking epoetin alfa (Procrit). Which laboratory result would be used to assess the effectiveness of this medication?
Correct Answer: A
Rationale: Red blood cells (RB
C) and hemoglobin (Hg) levels are directly affected by epoetin alfa, which stimulates red blood cell production in the bone marrow, making these values essential for assessing the medication's effectiveness. The leukocyte count (WB
C) is not relevant to the effects of epoetin alfa, as this medication primarily influences erythropoiesis. The erythrocyte sedimentation rate (ESR) is a non-specific test used to detect inflammation but does not provide information regarding the effectiveness of epoetin alfa. The thrombocyte count does not assess the effectiveness of epoetin alfa.