ATI RN
ATI N120n122 Med Surg Exam Questions
Extract:
Question 1 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 2 of 5
A nurse is caring for a client with Acquired Immunodeficiency Syndrome (AIDS). Which client statement demonstrates a need for further education?
Correct Answer: B
Rationale: Eating raw fruits and vegetables can pose a risk for clients with compromised immune systems, as these foods may harbor pathogens that can lead to infections. This statement indicates a need for further education regarding safe food handling and preparation. The other statements reflect appropriate practices for clients with AIDS.
Question 3 of 5
A nurse is caring for a client with iron-deficiency anemia. When teaching the client about nutrition, the nurse should educate the client which of the following foods contains the most amount of iron?
Correct Answer: D
Rationale: Red meat and organ meat are excellent sources of heme iron, which is more easily absorbed by the body compared to non-heme iron found in plant sources, making them the best choice for increasing iron intake in clients with iron-deficiency anemia. Milk and cheese, whole grain breads, and fresh fruits are not significant sources of iron.
Question 4 of 5
Select the appropriate treatment for the following transfusion reactions
| Options | Hemolytic reaction | Anaphylactic reaction |
|---|---|---|
| Administer 0.9% sodium chloride | ||
| Send the blood bag back to the blood bank for analysis. | ||
| Stop blood infusion | ||
| Administer epinephrine |
Correct Answer: A,B,C for Hemolytic; C,D,B,A for Anaphylactic
Rationale: For hemolytic reaction: Administer 0.9% sodium chloride to maintain fluid balance and prevent kidney damage, send the blood bag back for analysis to identify the cause, and stop blood infusion to prevent further hemolysis. For anaphylactic reaction: Stop blood infusion to prevent further exposure to the allergen, administer epinephrine to treat the severe allergic reaction, send the blood bag back for analysis, and administer 0.9% sodium chloride to maintain fluid balance.
Question 5 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.