ATI RN
ATI 410 Med Surg Exam Questions
Extract:
Question 1 of 5
A nurse is planning care for a client who is to receive packed RBCs. The nurse should plan for the total infusion time to not exceed which of the following?
Correct Answer: A
Rationale: The total infusion time for packed RBCs should not exceed 4 hours to minimize the risk of bacterial growth in the blood product, which can lead to sepsis and other serious complications. Infusing beyond 4 hours increases this risk significantly.
Question 2 of 5
In reviewing a patient's complete blood count (CBC) results, the nurse notes a 'shift to the left.' What is the significance of these results?
Correct Answer: B
Rationale: A 'shift to the left' indicates an increase in immature neutrophils (bands), often signaling acute infection or inflammation as the body releases more neutrophils to fight pathogens.
Extract:
Nurse's Notes:
Client admitted to the unit for a lower GI bleed. Continues to have frequent bloody stools and is scheduled for a lower endoscopy in 4 hr. The client is receiving their fourth unit of packed red blood cells (packed RBCs). Unit of fourth packed RBCs started at a rate of 250 cc/hr. Thirty minutes after the transfusion started, the client started reporting dyspnea and restlessness. Crackles auscultated in bilateral lower lobes. oxygen saturation 92% on 2L nasal cannula, and jugular vein distention noted.
Vital signs:
Temperature: 37.0°C (98.6°F)
Heart Rate (HR): 110 beats per minute
Blood Pressure (BP): 150/90 mmHg
Respiratory Rate (RR): 24 breaths per minute
Oxygen Saturation (SpO2): 92% on 2L nasal cannula
Question 3 of 5
Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress.
Correct Answer: B,C,D
Rationale: The client is experiencing transfusion-associated circulatory overload (TACO), indicated by dyspnea, crackles, jugular vein distention, and hypertension. Stopping the transfusion prevents further fluid overload, and furosemide removes excess fluid. Monitoring weight and respiratory rate assesses fluid status and respiratory distress.
Extract:
Question 4 of 5
A nurse is assessing a client who is receiving one unit of packed RBCs to treat intraoperative blood loss. The client reports chills and back pain, and the client's blood pressure is 80/64 mm Hg. Which of the following actions should the nurse take first?
Correct Answer: A
Rationale: Symptoms suggest an acute hemolytic transfusion reaction, a life-threatening emergency. Stopping the transfusion immediately is critical to prevent further reaction and hemolysis.
Question 5 of 5
A nurse is caring for a client who has shingles with multiple skin lesions. Which of the following actions by the nurse require intervention by the nurse's supervisor?
Correct Answer: B
Rationale: Shingles is highly contagious, especially to those without chickenpox immunity. Cohorting clients with shingles in a shared room risks viral transmission. Other actions are appropriate precautions.